In last week's column, we presented the topic of Antimicrobial Resistance (AMR) and highlighted how resistance to antibiotics is killing 700,000 people globally every year. We also observed how this resistance puts in manifest jeopardy life-saving interventions and procedures which are standard practice, including treatment for cancer patients.
The ECDC released a survey revealing gaps in European healthcare worker's knowledge and attitudes about antibiotics at last week's European Antibiotic Awareness Day 2019. The data from this survey "can be used [by each participating country] when developing locally adapted interventions to ensure prudent use of antibiotics, focused on changing behaviour and practice among healthcare worker, Andrea Ammon from the ECDC highlighted in the recent press on the results from the survey
Data is necessary for any country to identify the trends in hospitals and amongst patient and create national policies and guidelines. In fact, in an interview with Nedret Emiroglu, we learnt that the differences between the "healthcare systems and structures and also the traditions and cultures in the society about the use of medicines in particular antibiotics might explain why countries go at a different pace." Emiroglu is the Director of Health Emergencies and Communicable Diseases at WHO Regional Diseases at the WHO Regional Office for Europe.
18,365 healthcare workers from across the EU/EEA region were asked seven true/false knowledge questions. Only 58% of the respondents were able to answer all questions correctly. Nonetheless, 97% of the respondents correctly identified that antibiotics are not effective against colds and flu. This is a markedly higher number than that of the general public; only just over a half know that antibiotics are ineffective against colds.
This survey continues to contribute to an existing body of publications on AMR in national countries. In the 2018 ECDC's annual epidemiological report on Antimicrobial consumption in the EU/EEA region, Malta reported "significant increasing trends" in the average consumption of antibacterials for systematic use between 2009-2018. A similar increase can be seen in the use of carbapenems, also known as the last line of antibiotics, reserved for known or suspected multi-drug resistant bacterial infections.
The following excerpt from the report on the survey stands out: "Although the misuse or overuse of antimicrobials, particularly in human health, is a multifactorial issue. A lack of understanding and clarity about prudent antibiotic use and the spread of antimicrobial-resistant microorganisms, as well as relevant social and cultural factors, constitute important barriers to the prevention and control of AMR" Education was, in fact, one of the recurring themes in the majority of the speaker's presentation at the European Antibiotic Awareness Day 2019. Quoting one of Tony Blair's key quotes, "Education, education, education", Yvtenis Andriukaitis, outgoing Health and Food Safety European Commissioner cemented the number one priority for any government at last Monday's European Antibiotic Awareness Day launch event.
AMR currently costs Malta €3 million a year, one of the highest in Europe. If no immediate action is taken, the bill is only set to go higher. In fact, "[l]longer hospital stays, caused by slower recovery from infection and a higher risk of complications, will be one of the key drivers behind an increase in health care expenditure". In July 2017, the ECDC visited Malta to discuss antimicrobial resistance issues. The report on the visit acknowledged that there have been a few positive changes in the community and that oral antibiotics are now more difficult to obtain at a pharmacy without a medical prescription. Nonetheless, a substantial proportion of the Maltese population still doesn't know when they need to use antibiotics; many still believe that antibiotics would work on viral infections such as common cold and influenza. In fact, a recent Eurobarometer study shows that Malta has one of the highest antibiotic consumption in the EU.
In its recommendations, the ECDC highlighted the need for electronic prescriptions; these would allow for better monitoring of antibiotics distribution, and production of annual national AMR report for Malta. As reiterated above, the availability of data would pave the way for better strategies and action plans. Undergraduate courses and training schemes for healthcare professionals and training schemes should include education and training on AMR.
Malta was commended for developing a draft national AMR Strategy and Action Plan for the period of 2019-2025, which the ECDC has described as "comprehensive and ambitious". The final Strategy and Action Plan were published in November 2018 and was open for consultation until December 2018. It includes seven strategic priority areas for action including legislation and infrastructure, surveillance and training, continuous professional development education, building on the ECDC's country report the year earlier. However, what actions to combat AMR have taken place in the past year? It is crucial to start to move towards effective implementation of the Strategy.
On November 21, a new Member of European Parliament (MEP) Interest Group was launched to tackle AMR. The 12 founding Members, including Maltese MEP Roberta Metsola, confirms the need for stronger multistakeholder involvement and the role of the European Parliament, representing 500 million EU citizens, in boosting actions on AMR at EU level and encouraging national governments… to implement their national strategies on AMR. This initiative was described by Ann Marie Borg, Coordinator of the pan-European AMR Stakeholder Network, as "…a real milestone – ensuring that AMR remains high on the EU policy and political agenda. It is a strong signal towards finding real solutions to tackle one of the most serious health threats of our time, impacting the lives of many Europeans."
A top-down approach is intrinsic to the mitigation of AMR resistance. This does not, however, discount the fact that patients have an important role to play. Individual patients and patient groups networks need to come forward and speak up about how AMR is affecting their lives. In several areas within healthcare, namely HIV, personalised medicine, and IVF, patients have for long been the driving force in changing the field. We hope to see similar activism paths and action plans adopted by patient groups. AMR is here to stay unless the various stakeholders come together. Amongst them, patient groups.
We would like to thank Ann Marie Borg, the policy coordinator at the European Public Health Alliance (EPHA) for her contributions and insightful comments in the writing of this piece.