Swedish strategy to combat antibiotic resistance - Government ...

 
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Swedish strategy to combat antibiotic resistance - Government ...
Swedish strategy to combat
antibiotic resistance
Swedish strategy to combat antibiotic resistance - Government ...
Contents

Foreword................................................................................................................................3
Swedish strategy to combat antibiotic resistance...............................................5
Objective 1: Increased knowledge through enhanced surveillance ......................7
Objective 2: Continuous strong preventive measures...............................................8
Objective 3: Responsible use of antibiotics................................................................ 10
Objective 4: Increased knowledge for preventing and managing bacterial
              infections and antibiotic resistance with new methods.................. 12
Objective 5: Improved awareness and understanding in society
             about antibiotic resistance and countermeasures.......................... 14
Objective 6: Supporting structures and systems..................................................... 16
Objective 7: L
              eadership within the EU and at
             the international cooperation................................................................. 17
Past and present work in Sweden............................................................................ 20

Photo:
Jessica Gow/TT (cover),
Jessica Gow/TT (p 4, 13, 15)
Maskot/Folio (p 9),
John Sandlund/Folio (p 23).

The Government adopted this strategy on 21 April 2016
S2016/02971/FS Article no: S2016.007
Swedish strategy to combat antibiotic resistance - Government ...
Foreword

Antibiotic resistance is a problem of       including low profitability, but also
global dimension that affects us all.       the scientific difficulty of finding
                                                                                               The World Economic
The use of antibiotics is linked to         new approaches. In view of the com-
both the emergence and the spread           plexity of the problem, all of society             Forum has identified
of resistance.                              must come together and work within                 antibiotic resistance as
                                            a ‘One Health’ approach. The human                 a global risk beyond the
Genuine commitment and vigorous             and animal health care sector must                 capacity of any organiza-
actions are needed to combat antibio-       jointly ensure that antibiotics are used           tion or nation to manage
tic resistance if future generations will   in a responsible way, take preventive              or mitigate alone.
have effective remedies to our most         measures to limit the need for anti-
common infectious diseases. Antibio-        biotics and minimise the spread of
tics must be considered as a global com-    infections.
mon good and must be accessible to
anyone who needs them.                      Action is needed both from academic
                                            research and industry if new antibio-
Resistant bacteria are of particular con-   tics, vaccines and diagnostic methods
cern to the most vulnerable health          are to be developed. Issues related to
care sectors: emergency and intensive       environmental release of antibiotics
care units and neonatal units. Modern       require the involvement of the en-
health care depends on antibiotics,         vironmental sector. Resistant bacteria
particularly in connection to medical       are spreading between people and
procedures that involve an increased        animals, and in the environment.
risk of infection, e.g. cancer treatment,   Surveillance of resistance is hence
transplantations and operations. Infec-     needed at international, national and
tions caused by resistant bacteria can      local levels.
have serious consequences, from pro-
tracted hospitalisation to increased        All of society must be involved;
mortality. This means suffering for         numerous relevant actors could be
patients and increased costs for health     mentioned. To find global ways for-
and medical care. Similarly, infections     ward, the issue must be raised to
involving resistant bacteria can cause      Heads of States and Governments to
financial losses in the livestock indus-    ensure a true One Health perspective.
try and animal suffering. Low-income        Increased awareness among the gen-
countries are particularly severely af-     eral public is important regarding the
fected; limited access to clean water       consequences of widespread antibiotic
and sewage facilities, medicines and        resistance, both for individuals and
health care can dramatically increase       for society in general.
child mortality. Most deaths caused by
pneumonia among children under the          In May 2015, WHO member states
age of five are due to a lack of access     adopted a Global action plan on anti-
to effective antibiotics.                   microbial resistance, which provides
                                            a basis for the continuous work on
Antibiotic resistance is a complex pro-     antibiotic resistance. It is a top priority
blem. People, animals, food and other       for Sweden that the action plan is put
goods cross borders every day, contri-      into practice, all countries must take
buting to the spread of resistant bacte-    responsibility for fighting the pro-
ria. An increasing number of bacteria       blems of resistance. This problem
are developing resistance to existing       cannot be solved by individual coun-
antibiotics, while the development of       tries; it requires intense global efforts.
new classes of antibiotics has slowed
down. This is due to several factors,

                                                                                     Swedish strategy to combat antibiotic resistance   3
Swedish strategy to combat antibiotic resistance - Government ...
Working at the international level is             To tackle the problems of resistance,
vital to achieving national goals on              we need to make a concerted effort
preserving the possibility of treating            and coordinate our activities. To this
infections in humans and animals.                 end, we are presenting this Swedish
                                                  strategy to combat antibiotic resistance.
There is a broad political consensus in           The strategy points out the direction
Sweden on prioritising action against             of Swedish efforts and is also intended
antibiotic resistance. We have a long             for international actors wishing to
tradition of a broad and preventive               benefit from Swedish knowledge and
approach and as a result we have a                experience.
favourable resistance situation. Over
the years we have developed a high
level of expertise which is highly                Gabriel Wikström,
recognised in international forums.               Minister for Health Care,
This applies to policy issues, but also           Public Health and Sport
to the research area, where Sweden
has been deeply involved for several              Sven-Erik Bucht,
years, playing a role in the international        Minister for Rural Affairs
Joint Programming Initiative on
Antimicrobial Resistance. Sweden                  Helene Hellmark Knutsson
will continue to engage in advocacy               Minister for Higher Education
and set a good example.                           and Research

4   Swedish strategy to combat antibiotic resistance
Swedish strategy to combat antibiotic resistance - Government ...
Swedish strategy to combat
antibiotic resistance

 Antibiotic-resistant bacteria are spread globally in the same way as             This strategy is to form the basis of
 other bacteria. This means they can be transferred between people,               Sweden’s work to curb the develop-
 animals and foodstuffs, and they can spread in our environment.                  ment and spread of antibiotic resis-
 These links between the various sectors mean that efforts to combat              tance and to deal with the situation
 antibiotic resistance must be made from a broad perspective.                     we have today. The strategy is to high-
                                                                                  light areas and measures for effective
 This is called a One Health approach. It is important that the term              work to combat antibiotic resistance.
 One Health is understood in a way that all significant factors must be           Sweden’s work to combat antibiotic
 covered, such as issues concerning the economy, education, research              resistance must be long-term and sus-
 and aid, in order to deal globally with the problems of resistance.              tainable, and it must build on the good
                                                                                  international reputation Sweden has
 Health care environments are particularly at risk for the emergence              in this area.
 and spread of antibiotic resistance. Infections caused by resistant
 bacteria can have serious consequences, such as increased mortality              The strategy, which covers work at the
 and prolonged illnesses, and a reduced ability to protect patients               national level, as well as within the
 using antibiotics during a surgery and other medical procedures.                 EU and at the international level,
 This results in suffering for patients and increased costs for health            applies until 2020.
 and medical care services, and the society as a whole.
                                                                                  The global commitments made
 In addition, currently established treatment methods for diseases                within the 2030 Agenda, as well as
 such as cancer, as well as some areas of transplant surgery and other            Sweden’s Policy for Global Develop-
 advanced surgery, may need to be re-evaluated. This may, in time,                ment, are key frameworks for
 also apply to more common surgical procedures, such as prosthetics.              Sweden’s continued leadership in
                                                                                  the international work.
 In animal populations, resistant bacteria can spread quickly and
 thus represent a reservoir of bacteria that can spread further to both           The strategy is based on Sweden’s
 people and animals. Animals can also get infections that are difficult           current work to combat antibiotic
 to treat as a result of resistant bacteria. This causes suffering for the        resistance, the Global action plan
 animals and economic losses.                                                     on antimicrobial resistance that was
                                                                                  adopted by WHO member states at
 Important functions in society can also be affected by growing                   the World Health Assembly in May
 antibiotic resistance.                                                           2015, confirmed by FAO and OIE
                                                                                  resolutions, and relevant documenta-
                                                                                  tion, such as evaluations, action plans
                                                                                  and other strategies.

                                                                                  This strategy sets up an overarching
                                                                                  goal and seven strategic objectives
                                                                                  where the Government has identified
                                                                                  the important factors for achieving
                                                                                  these objectives. This strategy may be
                                                                                  supplemented with specific concrete
                                                                                  initiatives for various areas and sectors.

                                                                             Swedish strategy to combat antibiotic resistance   5
Swedish strategy to combat antibiotic resistance - Government ...
Overarching goal

Preserve the possibility of effective treatment of
bacterial infections in people and animals

6   Swedish strategy to combat antibiotic resistance
Objective 1: Increased knowledge
through enhanced surveillance

This objective involves:
• improving access to data on resistance and the sale
  and use of antibiotics and other antibacterial agents in
  all sectors, as well as access to data on the spread of
  antibiotics into the environment; and
• evaluating the success and cost-effectiveness of
  various measures, using continuous data collection.

It is necessary to continuously collect    ence how well treatment recommen-          • possibilities to systematically moni-
data on the occurrence of resistant        dations are used by prescribers (e.g.        tor the long-term trends concerning
bacteria and use of antibiotics. This      doctors and veterinarians). We have          resistance, sales and use of antibio-
enables us to analyse trends over          a long tradition in Sweden and high          tics, and human and animal infec-
time, see important changes that           level of expertise in surveillance, but      tions to be maintained and further
could indicate a spread of resistant       the systems used need to be improved         developed;
bacteria, quickly detect such a spread,    and further developed to become more
communicate findings and take mea-         effective and efficient, and to be adap-   • data about the reasons for prescrip-
sures at an early stage. Surveillance      ted to new challenges.                       tion and compliance with treatment
also makes it possible for us to moni-                                                  recommendations to be available
tor the effects of measures taken and      The Government expects:                      in all sectors and the results fed
to evaluate them.                          • appropriate data to be collected           back into relevant services.
                                             from relevant sectors and fed back
Using comparable resistance data from        where relevant at local, regional
various sectors, we can map out path-        and national level, as well as at EU
ways of spread and the significance of       and international level;
different sources for the resistance
problem. It is also important to be able   • efficient systems for early detection,
to link an antibiotic prescription to a      compilation, analysis and reporting
diagnosis so as to monitor and influ-        of information to be in place;

                                                90                                                              n Sweden
                                                                                                                n Denmark
                                                80                                                              n Netherlands
                                                                                                                n Spain
                                                                                                                n Germany
                                                70

Figure 1. Proportion of resistant               60
indicator bacteria (Escherichia coli)
in broilers 2014, an international              50
comparison.
                                                40

Source: The European Food Safety
                                                30
Authority and the European Centre
for Disease Prevention and Control
                                                20
2016, The European Union sum-
mary report on antimicrobial                    10
resistance in zoonotic and indica-
tor bacteria from humans, animals                0
and food in 2014.                                       Ampicillin       Quinolones         Tetracycline         Cefotaxime

                                                                                 Swedish strategy to combat antibiotic resistance   7
Objective 2: Continuous strong
preventive measures

This objective involves:
• identifying and implementing preventive measures
  in relevant sectors so that spread can be prevented,
  detected and avoided as early as possible;
• minimising the spread of multiresistant bacteria.

The favourable resistance situation               use and partly because of the spread
in Sweden does not mean we can be                 of bacteria to patients more suscepti-      An important success
complacent. Resistance is growing                 ble to infections. This, in turn, means     factor for effective natio-
here as well, albeit more slowly than             a greater risk of serious complications     nal work against antibiotic
elsewhere. We must remain vigilant                for these patients.
                                                                                              resistance has been close
and realise the importance of preven-
tive measures so that the situation               The need for antibiotics in animals         cooperation between the
does not deteriorate. Infection preven-           is reduced through efficient disease        local and national levels
tion measures will reduce the need for            control, good farm management,              in the health care sector,
antibiotics. People and animals that              biosecurity, and sound animal hus-          and also between central
are healthy or that receive good treat-           bandry systems. Safe international          government and the live-
ment or care will be less in need of              trade in both living animals and            stock industry.
antibiotics.                                      animal products is particularly impor-
                                                  tant. This also reduces the risk of
The national vaccination programmes               resistant bacteria spreading to other
and measures to maintain good hygie-              animals, to foodstuffs and to people.
nic standards in health care settings
are fundamental as infection preven-              Releasing antibiotics and other anti-
tion measures. Healthcare-associated              bacterial agents into the environment
infections are the most common                    can give rise to resistance. Although
adverse event in health care settings,            our knowledge about how antibiotics
and a number of these infections are              and other antibacterial agents can
caused by bacteria that have acquired             select for antibiotic-resistant bacteria
various resistance mechanisms.                    in the environment is incomplete,
Health care settings are particularly             there is data to indicate that this is an
sensitive for the development and                 important factor.
spread of antibiotic resistance, partly
because of the high level of antibiotic

8   Swedish strategy to combat antibiotic resistance
The Government expects:                     control regarding infectious
• a high level of compliance with vac-      diseases in order to ensure good              Responsible and sustain-
  cination and health programmes to         animal health and safe foodstuffs;            able breeding practices
  be maintained to keep people and                                                        in animal husbandry are
  animals as healthy as possible, thus    • antibiotic resistance, infection pre-
                                                                                          prerequisites for healthy
  reducing the need for antibiotics;        vention and control/hygiene to be
                                            included in relevant education and            animals, in need of less
• relevant staff to have knowledge          training programmes;                          antibiotics.
  about antibiotic resistance, the
  spread of infectious diseases and       • a high level of vigilance, rapid dia-
  the importance of a high degree           gnoses, and established routines
  of compliance with basic hygiene          and guidelines to prevent, detect
  routines and other infection pre-         and stop the spread of infectious
  vention measures, as well as know-        disease;
  ledge about the seriousness and
  complexity of the issue from a          • technology for the cleaning of
  global perspective;                       pharmaceutical residues and other
                                            substances that are difficult to
• county councils and municipalities        treat in water treatment plants to
  to have access to expertise regar-        be tested and evaluated by 2018;
  ding basic hygiene in health care
  settings so that good hygiene           • the development of rules on good
  standards can be maintained;              manufacturing practice and criteria
                                            in support of the county councils’
• relevant actors in animal produc-         procurement processes so as to
  tion, veterinary medicine, and the        move towards minimising releases
  food chain to have access to exper-       of antibiotics into the environment
  tise on hygiene and efficient disease     during pharmaceutical production.

                                                                                Swedish strategy to combat antibiotic resistance   9
Objective 3: Responsible use
of antibiotics

This objective involves:
• using and handling antibiotics and other anti-
  bacterial agents in a wise and responsible manner.

Increased use of antibiotics leads to an           plications arise due to insufficient
increased risk of development of resis-            treatment.                                 Sweden has the lowest
tance. Equally, the risk of resistance                                                        level of antibiotic use in
increases if antibiotics are used incor-           Recommended first-choice drugs             food-producing animals
rectly, for example in inappropriate               that are available in other EU Member
                                                                                              in the EU.
doses or using antibiotics with an un-             States are not always available in
justifiably broad antibacterial spectrum.          Sweden. This could pose a risk that
It is therefore important that antibiotics         more expensive second-choice drugs         The use of antibiotics
and other antibacterial agents are only            are prescribed, alternatively pharma-      as growth promoters for
used when they are needed, that the                ceuticals with negative side effects or    animals was prohibited in
right type of antibiotic is used and that          are worse from a resistance point of       Sweden in 1986 and in
treatment recommendations are deve-                view. Hence, it is therefore important
                                                                                              the EU in 2006.
loped and followed. To reduce the risk             that access to recommended first-
of development of resistance, it is im-            choice drugs is guaranteed. More
portant that drugs of particular impor-            knowledge is also needed on how the
tance for human medicine are not used              efficacy of older antibiotics can be
for animals.                                       optimised and preserved.

Data on compliance to treatment                    There is a risk that the widespread
recommendations must be fed back                   – and in many cases unnecessary – use
to the prescribers to ensure that pre-             of antibacterial agents in everyday pro-
scribing are made in the correct way.              ducts could be a contributing factor
It is also important to be able to moni-           to the emergence and spread of resis-
tor that antibiotic prescribing do not             tant bacteria.
decrease to such an extent that com-

10   Swedish strategy to combat antibiotic resistance
Belgium
            Bulgaria
             Cyprus
          Denmark
             Estonia
             Finland
             France
             Ireland
                 Italy
               Latvia
          Lithuania
       Luxembourg
    The Netherlands
             Poland
           Portugal
            Slovakia
           Slovenia
               Spain
    United Kingdom
            Sweden
     Czech Republic
          Germany
           Hungary
             Austria

                         0       50        100      150       200       250          300         350         400         450

    Figure 2. Sales of veterinary antimicrobial agents for food-producing animals in the EU. Expressed as mg of
    active substance per Population Correction Unit (PCU). PCU corresponds to the total weight of live animals
    within a country, expressed in kilograms. The measure is not exact and should therefore be interpreted with
    caution. Source: Fifth ESVAC report 2013, European Medicines Agency.

The Government expects:
• antibiotics to, continuingly, only be      cines used for treating animals,            • antibiotics of particular importance
  used following a prescription from         especially as regards production              to continue to be given to animals
  professionals that are authorised to       animals, in order to facilitate con-          only when there are exceptional
  prescribe antibiotics;                     trols regarding compliance with               grounds for doing so;
                                             treatment recommendations;
• recommendations to be drawn up                                                         • environmental data to make up
  at the relevant level (local, regional   • the regular use of quality-assured            part of the basis of the approval
  or national) concerning the diag-          microbiological diagnostics with              process of antibiotics and to be
  nosis and handling of common in-           as short response times as possible,          made available to government
  fections within both human health          so that unnecessary and incorrect             agencies and other relevant stake-
  care and veterinary care, and that         treatment can be avoided;                     holders for the assessment of
  those recommendations will be har-                                                       environmental risks;
  monised as far as possible and used      • access to both new and older anti-
  in day-to-day work;                        biotics to be guaranteed on the             • discarded antibiotics to be dealt
                                             Swedish market;                               with in an environmentally sound
• data on compliance with treatment                                                        way;
  recommendations to be accessible         • increased knowledge about how the
  for prescribers, service managers,         availability and use of new antibio-        • antibacterial agents to be used in a
  government agencies and the pub-           tics and older antibiotics – where            prudent, responsible and evidence-
  lic, in both human and veterinary          national availability is inadequate           based way in various types of con-
  medicine;                                  – can be guaranteed, while at the             sumer products.
                                             same time the risk of developing
• data to be available regarding             resistance is minimised and the
  reasons for prescription of medi-          best possible care is provided;

                                                                                    Swedish strategy to combat antibiotic resistance   11
Objective 4: Increased knowledge for
preventing and managing bacterial
infections and antibiotic resistance
with new methods

This objective involves:
• increasing knowledge about basic bacterial infection
  mechanisms so that new diagnostic methods, vaccines
  and treatment options can be developed;
• increasing knowledge about the emergence and spread
  of resistance so that the use of new and existing antibio-
  tics can be optimised and the extent of the resistance
  problem can be prevented and limited.

One contributing factor to the serious-            biotic resistance for the health sector.
ness of the resistance problem is that             The effects of actions taken must be        Antimicrobial resistance
the development of new antibiotics                 measurable as well as the economic          refers to resistance among
and other treatment options has slow-              consequences of resistance. The costs       bacteria, viruses and other
ed down. This is due to several fac-               and benefits of antibiotic use and resis-
                                                                                               microorganisms, whereas
tors, including low profitability, but             tance in animal production must be
also the scientific difficulty of finding          possible to estimate to justify further     antibacterial resistance
new approaches. To enable the deve-                improvements at national and inter-         (antibiotic resistance) ref-
lopment of new treatment strategies                national levels. Increased knowledge        ers only to resistance in
and preventive measures, research is               is also needed about how the structure      bacteria.
necessary into how bacteria give rise              of health and medical care systems,
to infections and what other factors               animal production, global trade and
affect which individuals are infected              tourism affects the spread of antimi-
and how severely they are affected.                crobial resistance between bacteria,
Equally, research is needed to be able             people, animals and the environment.
to optimise and preserve the efficacy
of existing treatments for as long as              These challenges cannot be solved
possible. The development of cost-                 by individual nations; they require
effective methods for better infection             coordinated international cooperation
diagnostics and sensitivity tests could            spanning many sectors. The EU is an
reduce the incorrect use of antibiotics            important platform for the work to
in health care, veterinary medicine                be carried out by Sweden.
and animal husbandry.

Moreover, there is a need for new
knowledge to be able to estimate the
burden of disease and costs of anti-

12   Swedish strategy to combat antibiotic resistance
The Government expects:                   • Sweden to take part in international
• research to be carried out in the         research cooperation in the area of
  area of antibiotic resistance, inclu-     antibiotic resistance and related
  ding research into how resistance         areas;
  develops and spreads, into how
  existing and new antibiotics can        • universities and other higher edu-
  be optimally used to prevent the          cation institutions, government
  emergence of resistance, into com-        agencies, health and medical care
  municable disease control and             institutions and the industry to col-
  preventive measures, and into the         laborate at national level, within
  consequences of antibiotic resis-         the EU and at international level to
  tance – for the economy, for health       identify and bridge knowledge gaps;
  and for society in general;
                                          • Sweden to contribute to the deve-
• research to be carried out into basic     lopment of knowledge about new
  bacterial infection mechanisms;           business models and financial in-
                                            centives to stimulate the develop-
• research to be carried out into how       ment of new antibiotics and other
  new strategies and other knowledge        treatment options.
  can best be implemented in relevant
  activities;

• measures to be taken to bridge the
  gap between basic research and
  the commercialisation of research
  findings;

                                                                                 Swedish strategy to combat antibiotic resistance   13
Objective 5: Improved awareness
and understanding in society
about antibiotic resistance and
countermeasures

This objective involves:
• knowledge, competence and increased awareness
  among all relevant parties – including the general
  public – about measures to prevent the spread of
  infections and about the risks of resistance develop-
  ment through the use of antibiotics.

Antibiotics are only available on pre-             important that information is co-
scription in Sweden, prescribers have              ordinated within each sector and           The responsible use of
the full responsibility to use them                between sectors so that the general        antibiotics, infection pre-
wisely. However, the public’s know-                public will have the same message          vention and a high level of
ledge and expectations can influence               from all actors. Collaboration makes
                                                                                              knowledge among health
decisions about prescribing antibiotics.           it easier to produce information tailor-
Therefore, a high level of awareness               ed to specific needs.                      care staff are prerequisites
about why it is important that anti-                                                          for preventing healthcare-
biotics are only used when they are                The Government expects:                    associated infections.
needed is essential for building a                 • people working in health care and
sustainable approach in the society to               social services, dental care, with
antibiotics. Equally, a high level of                animals and with food production
awareness about the importance of                    to have good knowledge of the
good hygiene and preventive measu-                   One Health concept, antibiotics,
res are important to reducing the                    antibacterial agents, general
spread of infectious diseases and thus               hygiene, hygiene in health care
the need for antibiotics. It is also im-             settings and infection control;
portant that consumers are given the
opportunity to make well informed                  • patients and animal keepers to
decisions. For example, labelling of                 have good knowledge about the
the origin of meat can help consu-                   importance of using antibiotics
mers choose meat from countries                      as prescribed;
with prudent use of antibiotics in
animal production.                                 • national, regional and other rele-
                                                     vant parties to collaborate to prod-
Many actors in Sweden are currently                  uce and disseminate tailored and
working to disseminate information                   coordinated information about
and knowledge about antibiotic resis-                antibiotics and antibiotic resistance,
tance and preventive measures via                    general hygiene and other preven-
their channels and networks. This is                 tive measures.
a strength but at the same time, it is

14   Swedish strategy to combat antibiotic resistance
Swedish strategy to combat antibiotic resistance   15
Objective 6: Supporting structures
and systems

This objective involves:
• conducting work related to antibiotic resistance in a
  coherent, efficient and strategic manner on the basis
  of the roles of different stakeholders;
• this work being followed up and lessons learned.

Work to prevent and handle antibiotic              The Government expects:
resistance spans across several sectors            • the Government Office to be well-      The Public Health Agency
and actors. Clear systems and struc-                 coordinated in its work on issues      of Sweden and the Swedish
tures for collaboration are needed to                concerning antibiotic resistance;      Board of Agriculture have
make use of the accumulated know-                                                           been tasked by the govern-
ledge that exists among the different              • a national coordination function
                                                                                            ment to jointly coordinate
stakeholders and to identify know-                   with relevant government agencies
ledge gaps. Coordination enables re-                 and other stakeholders to coordi-      the work against antibiotic
sources to be used more efficiently                  nate overall national work;            resistance and healthcare-
and helps to avoid duplication of work                                                      associated infections in
and to communicate coordinated                     • the Swedish strategic programme        Sweden.
messages.                                            against antibiotic resistance
                                                     (Strama) to lead national work and
Successful work to contain antibiotic                to coordinate the county councils’
resistance builds on support for the                 Strama groups, that support and
implementation of measures targeting                 monitor activities in work on the
both individuals and targeting the                   prudent and responsible use of anti-
development of supporting structures                 biotics for humans. Within the
in the organisations. For example,                   animal and food sector, Strama
established systems related to the                   VL (for the veterinary and food
follow-up of antibiotic use and com-                 sectors) continues to provide know-
pliance with treatment recommenda-                   ledge support to various stake-
tions can influence how and when                     holders);
antibiotics are prescribed.
                                                   • knowledge to be developed and
                                                     used regarding how organisational
                                                     factors should support the work on
                                                     antibiotic resistance.

16   Swedish strategy to combat antibiotic resistance
Objective 7: Leadership within the EU
and in international cooperation

This objective involves:
• Sweden showing leadership in efforts to combat antibiotic
  resistance and to work for the prudent and responsible
  use of antibiotics globally in multilateral processes, work
  at EU level and in bilateral contacts and cooperation;
• global commitments made as part of the 2030 Agenda,
  as well as Sweden’s Policy for Global Development,
  being key frameworks.

Antibiotic resistance is a global pro-        Sweden has currently a favourable
blem that requires many countries             situation, with regard to resistance,            The Swedish strategic
contributing to the solution. The             but this can change quickly as a result          work has a long tradition
major international organisations             of travel and trade and depending on             of collaboration between
WHO, FAO and OIE are platforms                how resistance develops and spreads              all relevant sectors and
for this work. The political will to act      internationally. This is why Sweden
                                                                                               disciplines such as the
on the threat of resistance has grown         needs to contribute to work so that
throughout the world in recent years.         the resistance status of other countries         human, animal, food and
The fact that in 2015, WHO members            is also improved. Sweden’s relatively            the environment sectors.
adopted the Global action plan on             good situation is a result of long and
antimicrobial resistance to gives con-        laborious work, which has led to a
crete form to and speeds up efforts is        very high level of expertise on anti-
proof of this. In light of this, it is also   biotic resistance that is asked for inter-
important to stress that the global           nationally. Different countries have
action plan is based on a clear One           different situations when it comes to
Health approach, where measures               tackling the resistance problem. For
have also been identified in the area         example, there may not be sufficient
of agriculture and are supported by           data for new treatment recommen-
both the FAO and OIE. These orga-             dations. Equally, many countries lack
nisations adopted at the same time            health and medical care systems and
resolutions to support the global             veterinary agencies that have the
action plan in their areas of expertise.      capacity to implement these recom-
However, international pressure is            mendations.
still needed to move the issue high up
on the agenda in all countries and to         Healthy animals are the overall objec-
increase awareness in all relevant            tive in animal husbandry in Sweden.
sectors.                                      Strategies based on improving animal
                                              health result in a reduced spread of
                                              infectious diseases and a reduced use

                                                                                      Swedish strategy to combat antibiotic resistance   17
of antibiotics. Preventive animal                  tend not to reach the poorest people.
health measures and low levels of anti-            The problems of antibiotic resistance     Every year, the Public
biotic use in animal production result             are also present in the area of sexual    Health Agency of Sweden
in a favourable resistance situation.              and reproductive health and rights.       and the National Veterinary
However, the resistance problem is                 Maternal and child mortality, infec-      Institute publish a joint
not tied to national borders; for ex-              tions in new-borns and resistant
                                                                                             report giving an overview
ample, resistance can spread via the               gonorrhoea are some of the areas that
international trade of animals. To get             risk being hit hardest by antibiotic      of the resistance status
to grips with the resistance problem               resistance. Efforts to combat anti-       and antibiotic use.
in animal production, it is therefore              biotic resistance in developing coun-
necessary for other EU Member                      tries have traditionally focused on the
States to take similar measures to                 health sector. However, the nature of
those already implemented in Sweden.               the resistance problem means that
This is also important from a com-                 a broader approach is desirable,
petitiveness perspective, so that the              including preventive measures that
animal keepers who continuously                    cover the environmental sector and
work to reduce antibiotic use are not              animal production, as well as the
disadvantaged. Sweden must there-                  health sector.
fore try to influence the other EU
Member States to continue to work                  Knowledge about how antibiotic use
with strategies based on improving                 and resistance affect economic and
animal health and using antibiotics                social aspects is generally poor glo-
in a more responsible way in animal                bally. By producing such knowledge,
production.                                        analyses and models, we can influence
                                                   understanding of this problem to a
The fact that many international                   higher degree. For example, the
initiatives are under way to manage                OECD has shown through a study
antibiotic resistance is good news.                financed by Sweden that the costs of
However, resources are required to                 ceasing to use antibiotics as growth
follow and coordinate various initi-               promotors in animal production are
atives and to actively participate in              relatively low in wealthy nations
them. By channelling resources                     in the world. More such studies are
through the EU, the large internatio-              needed to monitor development and
nal organisations and the cooperation              as incentives for change.
between the Nordic countries, we can
improve the leverage of our resources.             The Government expects:
Sweden also has bilateral agreements               • Sweden to support the WHO,
with certain countries where we can                  FAO and OIE in efforts to combat
focus on special initiatives.                        antibiotic resistance, also within
                                                     the framework of the EU and
Antibiotic resistance risks under-                   Nordic cooperation. It is particu-
mining a series of advances that have                larly important to support the im-
been made through the Millennium                     plementation of the Global action
Development Goals, as infections                     plan on antimicrobial resistance.
caused by resistant bacteria occur to                The focus of Sweden’s engagement
a disproportionately high degree in                  should be on building up a global
developing countries. Lack of access                 surveillance system for antibiotic
to water, sanitation, health and med-                resistance. In the long term,
ical care and relevant antibiotics are               Sweden should work for integrated
some of the causes. Moreover, mea-                   global surveillance systems for
sures to reduce antibiotic resistance                antibiotic resistance and antibiotic

18   Swedish strategy to combat antibiotic resistance
• use in humans and animals and,            broad approach that also includes,
  where appropriate, also in food-          in addition to the health sector, for
  stuffs, in cooperation with the           example the environmental and
  WHO, FAO, OIE and the Codex               agricultural sectors. Sweden should
  Alimentarius;                             also, in the international coopera-
                                            tion, make use of experiences from
• Sweden to continue building allian-       other countries and learn from
  ces with other countries in order to      others;
  advance the antibiotic resistance
  issue at a high political level, e.g.   • Sweden to cooperate with other
  through a high-level UN meeting           EU Member States, the European
  in 2016. The purpose is to raise          Commission and the EU agencies
  important overarching issues that         on the implementation of the EU
  cannot be solved by the health            Action Plan against the Rising
  sector and the agricultural sector        Threats from Antimicrobial
  alone. This concerns issues such          Resistance. In working on a new
  as access to and the correct use          EU action plan, Sweden should
  of new and old antibiotics, and           argue for concrete and clear
  diagnostic methods and other treat-       objectives;
  ment methods. These are impor-
  tant issues for ensuring that the       • Sweden to be a driving force in
  problem with resistance will not          negotiations concerning new
  increase and the new antibiotics do       regulatory frameworks, recom-
  not quickly become ineffective;           mendations and guidelines in the
                                            EU to work towards the respon-
• Sweden to continue pushing for            sible use of antibiotics in animal
  the OECD to develop economic              production;
  analyses about the consequences
  of antibiotic resistance in both the    • Sweden to continue its involvement
  agricultural sector and the human         in the EU Joint Programming
  health sector;                            Initiative on Antimicrobial
                                            Resistance;
• Sweden to continue working as
  one of the leading countries in the     • Sweden to work to ensure that
  action package for antimicrobial          increased environmental conside-
  resistance under the Global Health        ration is taken into account in the
  Security Agenda (GHSA);                   EU pharmaceuticals legislation
                                            and internationally, for example
• Sweden to work for a global phase-        should a regulation on minimum
  out of the use of antibiotics as a        requirements for production
  growth promoter in animal pro-            conditions be considered;
  duction and of other routine use
  of antibiotics in animals, and for a    • Sweden to promote issues related
  transition to sustainable produc-         to antibiotic resistance through
  tion systems;                             bilateral agreements with other
                                            countries.
• Sweden to share knowledge and
  experiences with other countries,
  considering in particular the needs
  of low-income countries. In this
  work, Sweden should argue for a

                                                                                  Swedish strategy to combat antibiotic resistance   19
Past and present work in Sweden

The basic idea behind the Swedish                  Today there is a strong consensus         Sweden is a result of regulated sales
work against antibiotic resistance is              amongst the country’s animal health       of antibiotics both on the animal and
that an overall low infection rate in              organizations, veterinary personnel       the human side, and sound surveil-
the society leads to a healthy popula-             and professional animal keepers on        lance of the prescription of antibiotics.
tion and healthy animals with lesser               restrictive and responsible antibiotic    Treatment recommendations for
need of antibiotics. This in turn leads            use. Sweden has a long tradition of       infections, both the within health
to a reduced selection of resistant bac-           preventive work to keep the animals       care and dental care, are produced
teria. Prevention control practices                healthy, and healthy animals need         and updated by the Medical Products
may include anything from vaccina-                 little antibiotics.                       Agency and the Public Health Agency.
tions, good diagnostics, good hygiene,                                                       Corresponding work regarding vet-
active animal health work and good                 We carry out continuous resistance        erinary medicine has been performed
animal husbandry, to public health                 surveillance in Sweden and are well       for the major domestic animal species
interventions against lifestyle diseases           informed about the current resistance     by the Medical Products Agency and
directed towards the profession as                 situation. Samples are often collected    by the Swedish Veterinary Associa-
well as the general public.                        from patients within the health care      tion. Furthermore, the Swedish Board
                                                   system which provides us with data        of Agriculture has adopted regulations
Significant attention has been paid, at            for surveillance. Sweden has also in-     on antibiotics that should not be given
an early stage, to antibiotic resistance           vested in well-functioning standardi-     to animals.
in Sweden, and measures were taken                 zed laboratories. The systems for sur-
to prevent the spread of resistant bac-            veillance of antibiotic resistance are    In order to further support optimized
teria and to limit the unnecessary use             based on voluntary participation of       use of antibiotics through surveillance,
of antibiotics. Due to close collabora-            laboratories complementing the not-       analysis and feedback on compliance
tion between government agencies                   ifications made in accordance with        to treatment recommendations, data
and interested parties representing                the Communicable Diseases Act.            is needed that links prescription with
animal husbandry, Sweden was the                   The Public Health Agency analyses,        diagnosis.
first country within the European                  compiles and provides feedback of
Union to prohibit antibiotic additives             national data of antibiotic resistance    Antibiotic resistance has been a prio-
as growth promoters in animal feed-                and antibiotic use, and the incidence     ritised research topic in Sweden for
stuff. This was already in place 1986.             of health care associated infections.     many years. The latest research and
                                                                                             innovation government bill included
The favourable situation, from an                  Sweden also has a programme for           a focus on antibiotics and infection,
international perspective, as regards              monitoring of antibiotic resistant bac-   resulting in graduate schools and re-
antibiotic resistance in humans and                teria in food producing animals and       search grants within this area. Sweden
animals is a result of early awareness             food. The Swedish National Veteri-        was also – along with Italy – the initi-
of the problem. One example is the                 nary Institute is responsible for this    ator of the international research col-
low prevalence of methicillin resistant            monitoring, regarding food this work      laboration that was initiated in the
Staphylococcus aureus (MRSA) (see                  is conducted in collaboration with the    field of antibiotic resistance in 2010,
figure 3, page 21). Also, this bacteri-            National Food Agency. Through             Joint Programming Initiative on
um has yet not become established in               yearly surveillance of antibiotic resi-   Antimicrobial Resistance. Today the
our Swedish pig population. From an                dues in meat, samples are taken in        collaboration includes 22 countries,
international perspective, Sweden has              order to ensure that animals used for     of which several are non-European.
a relatively low use of antibiotics per            food production will not be treated       Sweden had the presidency for the
capita (see figure 4, page 22). Pres-              with antibiotics prior to slaughter.      first six years and the secretariat is
cription of antibiotics has decreased                                                        located at the Swedish Research Coun-
since the middle of the 1990s, we have             The results from the surveillance         cil. JPIAMR has developed a strategic
seen a total decline with over 40 per-             of resistance and antibiotic use in       research agenda, which has formed
cent. For animals the use of antibio-              humans and animals are presented          the basis for several countries’ national
tics is the lowest within the EU. The              annually in a joint report by the         agendas.
total amount of antibiotics given to ani-          Swedish National Veterinary Institute
mals in Sweden has decreased by 60                 and the Public Health Agency.
percent since the middle of the 1980s.             The relatively good situation in

20   Swedish strategy to combat antibiotic resistance
Figure 3. Staphylococcus aureus. Percentage (%) of invasive isolates with
resistance to meticillin (MRSA), by country, EU/EEA countries, 2014

          < 1%                        25% to < 50%                                     Non-visible countries

          1% to ≤ 5%                  > 50%                                                         Liechtenstein

          5% to < 10%                 No data reported or less than 10 isolates                     Luxembourg

          10% to < 25%                Not included                                                  Malta

                                                                                  Swedish strategy to combat antibiotic resistance   21
In order to coordinate the work of                                              The county councils and the regions’                 The Strama group for dental care
       the national government agencies,                                               local Strama groups can disseminate                  develops and supports the implemen-
       a national intersectoral coordinating                                           knowledge on treatment recommen-                     tation of treatment recommendations
       mechanism was established in 2012                                               dations and give feedback on indivi-                 as 0well as disseminates knowledge
       for antibiotic resistance and health                                            dual prescription data and resistance                on antibiotics within Swedish dental
       care associated infections. The Public                                          level to prescribers. Today the Strama               care. Strama VL (veterinary and food
       Health Agency and the Swedish Board                                             groups are a part of the Swedish                     stuff) is a network where a broad
       of Agriculture are jointly responsible                                          Association of Local Authorities and                 group of interested parties participa-
       for this function, 21 government                                                Regions where they have established                  tes. The Swedish National Veterinary
       agencies participate in this mechanism.                                         the Strama Programme Council.                        Institute has been mandated to sup-
                                                                                       Close contact and good collaboration                 port this collaboration and therefore
       Other success factors is the regional                                           between national government agencies                 hosts a Strama VL secretariat. The
       and local work within the Swedish                                               and the regions, county councils and                 secretariat shall promote coordination,
       Strategic programme against antibiotic                                          local authorities will first and fore-               be a point of contact and a centre of
       resistance (Strama), the clinical micro-                                        most guarantee strong implementa-                    knowledge.
       biological laboratories, the infection                                          tion of knowledge and evidence-
       control units, the communicable dis-                                            based action.
       ease control units and the drug thera-
       peutic committees.

        Figure 4. Consumption of Antibacterials For Systemic Use (ATC group J01)
        in the community (primary care sector) in Europe, reporting year 2014

                                       35

                                       30
DDD per 1000 inhabitants and per day

                                       25

                                       20

                                       15

                                       10

                                        5

                                        0
                                                 ce nia* nce ium Italy rus urg alta land land pain atia aria akia om ugal land blic land gary ania way ark any enia stria den tvia onia nds
                                              ee        a   g           p  o M re            S Cro ulg lov ingd ort Ice epu Fin un thu Nor enm erm lov Au we La Est erla
                                            Gr oma Fr Bel           Cy emb       I     Po           B    S K      P                   H Li                  S         S
                                              R                         x                                     d            hR                      D   G
                                                                                                                                                                                 Ne
                                                                                                                                                                                    th
                                                                    L u                                   ite           ec
                                                                                                       Un            Cz

                                            *Country provided only total care data.
                                            *Country provided only total care data.

   22                                  Swedish strategy to combat antibiotic resistance
”For animals the use of antibiotics is the lowest within the EU”

                                                       Swedish strategy to combat antibiotic resistance   23
Ministry of Health and Social Affairs
103 33 Stockholm
government.se
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