Cheryl Goh Channel NewsAsia 1 Nov 17;
SINGAPORE: A national strategic action plan has been developed by Singapore One Health agencies to tackle the problem of antimicrobial resistance (AMR).
This was announced by Senior Minister of State for Health Lam Pin Min at an AMR public health dialogue on Wednesday (Nov 1).
The World Health Organisation defines AMR as the ability of microorganisms such as bacteria, viruses and some parasites to stop an antimicrobial, such as antibiotics, from working against it.
This means that standard treatments become ineffective, and infections persist and may spread to other people.
Developed by the One Health Antimicrobial Resistance Workgroup, which comprises the Ministry of Health (MOH), Agri-Food and Veterinary Authority, National Environment Agency and National Water Agency PUB, the action plan provides a framework to strengthen and enhance activities to combat AMR, address identified gaps and prioritise future interventions, the agencies said in a joint release.
It aims to reduce the emergence and prevent the spread of drug-resistant microorganisms through five core strategies.
These are education, surveillance and risk assessment, research, prevention and control of infection, and optimisation of antimicrobial use.
Dr Lam said that the group is also looking into strengthening public education efforts on AMR.
This could include activities in schools to "engage our children from a young age" and teach them about "simple steps" like maintaining personal hygiene as well as a more in-depth understanding of how antibiotics work.
"It is only a matter of time after the discovery of an antimicrobial and its introduction to market that a microorganism develops resistance to it, often fuelled by the overuse or abuse of these antimicrobials," said Dr Lam.
"The extreme scenario of AMR – of having no effective antibiotics to treat infections, will bring us to a post-antibiotic era where simple infections may kill."
He pointed out that even today, there exist infections that do not respond to many treatment options.
"We must therefore take action now," he said.
To this end, Dr Lam also identified three term longer-term efforts needed to combat AMR.
The first of these is integration, said Dr Lam, which is the need to coordinate efforts across sectors.
“In human health, MOH has been supporting surveillance of resistant infections and antimicrobial usage in public hospitals," he said.
"Hospital surveillance teams actively monitor AMR and data from such activities have enabled the implementation control measures to prevent the transmission of infections by resistant microorganisms."
The second is in-depth research, to understand the complex factors influencing AMR and to develop innovative, evidence-based initiatives.
The third is recognising that AMR is a global problem, said Dr Lam, and that Singapore domestic efforts must complement work done by international counterparts.
Source: CNA/nc
National strategy launched to halt the march of drug-resistant bacteria
LOUISA TANG Today Online 2 Nov 17;
SINGAPORE — To stop the threat of drug-resistant bacteria from spiralling out of control, the authorities announced a national strategy on Wednesday (Nov 1) that will cut improper use of antibiotics in humans and locally farmed animals.
Announcing the launch of the National Strategic Action Plan on Antimicrobial Resistance nearly a year after work on it was first reported, Senior Minister of State for Health Lam Pin Min stressed the need to take action now.
“The extreme scenario of antimicrobial resistance – of having no effective antibiotics to treat infections – will bring us to a post-antibiotic era where simple infections may kill. Even today, there exist infections that do not respond to many treatment options,” said Dr Lam at a public-health dialogue on the subject at the National University of Singapore.
Antimicrobial resistance occurs when disease-causing microbes, such as bacteria, viruses or parasites, grow resistant to the effects of medicine that used to be able to kill them.
Guidelines on appropriate use of antibiotics and other antimicrobial medicines in primary care clinics and community settings will be issued. Local studies have found that the majority of primary care doctors believed antibiotics are over-prescribed in primary care. Incentives could be offered to encourage doctors to optimise antimicrobial use, according to the plan.
The topic will be expanded in undergraduate and postgraduate training of doctors, and the authorities will also organise campaigns to educate the public on the myths and bad practices of antibiotics use. Messages will include the fact that antibiotics do not work for viral infections.
Professor Teo Yik Ying, Vice-Dean of Research and Dean-Designate at the NUS Saw Swee Hock School of Public Health, said it is important for both general practitioners (GPs) and individuals to know when not to prescribe or request for antibiotics.
The authorities need to “send a message” to GPs and polyclinics that they should not prescribe antibiotics just because patients ask for it, he noted.
When dispensing antibiotics, doctors should also remind patients to “follow the regulations and instructions on finishing the course of antibiotics, and not to stop the course whenever a patient feels better”, he added.
Antimicrobial resistance is a problem worldwide.
Globally, 480,000 people develop multi-drug resistant tuberculosis each year and drug resistance is starting to complicate efforts to tackle malaria and the AIDS-causing human immunodeficiency virus, according to the World Health Organisation.
The Infectious Diseases Society of America estimates that half or more of outpatient antibiotic prescriptions for some common infections are unnecessary or inconsistent with current guidelines.
Agencies in Singapore have some measures in place but the national plan identifies “priority areas” that involve more work and research.
For instance, all public acute hospitals have had antimicrobial stewardship programmes since 2011 to guide doctors in making appropriate choices, but the programmes will be reviewed to be more effective.
Surveillance of drug-resistant infections will be stepped up to include private hospitals and the community, instead of only public hospitals.
And in food production, the Agri-Food and Veterinary Authority (AVA) routinely tests animal feed, meat, dairy products, eggs and egg products, honey and drinking water for antibiotic residues. It will strengthen this by ensuring test methods remain relevant.
To do risk assessments, more data and studies will be needed. For instance, humans can be exposed to drug-resistant organisms in the food chain but the agencies said “more clarity is needed”.
“Little is currently known about the occurrence, effects, biodegradation and significance associated with the release and accumulation of antimicrobials in the environment,” the plan noted. “There is a need to understand how antimicrobials (including disinfectants) may contribute to the selection and spread of drug-resistant organisms in the natural environment and throughout the water and used-water treatment processes.”
One way of prevention and infection control is through immunisation.
The MOH introduced the National Adult Immunisation Schedule last month and will monitor vaccine uptake.
Professor Teo said vaccinations would greatly aid in the fight against antimicrobial resistance, being “a first-line defence” against preventable infections. The authorities will also promote the use of vaccines in livestock, pets and fish, to reduce reliance on antimicrobials. This will involve parties such as pet owners, vets and farmers.
Details on goals for the next five years, measures and ways to monitor outcomes will be developed, stated the plan by the One Health Antimicrobial Resistance Workgroup comprising the Ministry of Health, AVA, National Environment Agency and national water agency PUB.
How the national plan aims to reduce drug resistance in bacteria, viruses and fungi
Salma Khalik Straits Times 1 Nov 17;
SINGAPORE - Work to reduce drug resistance in bacteria, viruses and fungi has been ongoing in Singapore for years, but has been carried out in silos.
In a step to bring together the agencies involved – the Agri-Food and Veterinary Authority, the Health Ministry, the National Environment Agency and national water agency PUB – the Government set up a multi-ministerial committee in January to combat antimicrobial resistance (AMR) as a whole-of-government effort.
It has come up with a National Strategic Action Plan, which was launched on Wednesday (Nov 1). The plan looks at gaps in current efforts and suggests ways to deal with them to prevent the AMR problem from getting worse.
PEOPLE
- Greater awareness among people on the importance of using antibiotics correctly. For example, antibiotics are of no use against viral infections such as the flu.
- Getting more people to be vaccinated against infections. Fewer infections mean less need for antibiotics. The recently launched adult vaccination programme is a step in this direction.
- Strengthen AMR education among doctors. Many doctors believe antibiotics are overprescribed in primary care.
ANIMALS
- Greater education among veterinarians and farmers on the proper use of antimicrobials. This is because animals are fed antibiotics, and some of it would remain in the food we eat.
- Expand surveillance of bacteria and resistance to include all animal production sectors such as poultry and fish farms.
- Identify resistance against certain bacteria in poultry, diary and food-fish farms.
- Promote use of vaccines to prevent disease in animals and fish, rather than use drugs to treat them.
- Improve animal management process to reduce infectious diseases in animals, and thus, reduce the use of antimicrobials.
- Reduce inappropriate use of antimicrobials in food-producing animals.
INDUSTRY
- Educate the industry on the proper disposal of antimicrobial waste, as it could spread resistance. This includes not just farmers, but also manufacturers, distributors and pet owners.
- Standardise data reporting of resistant drugs and other related information for easier surveillance.
- Enhance laboratory testing capacity, including identifying a core panel of microbials for surveillance.
- Surveillance of drug-resistant organisms in retail food and meat. Identify risks and trends of drug-resistant organisms along the food chain, as people can become drug resistant this way.
- Surveillance of the environment, including water bodies and used water in treatment processes, which may harbour traces of antibiotics or drug-resistant organisms.
- Educate food handlers to maintain high levels of hygiene.
New workgroup set up to fight antimicrobial resistance
Salma Khalik Straits Times 1 Nov 17;
SINGAPORE - Microbial bugs are becoming increasingly resistant to drugs, making it more difficult to treat certain diseases.
To reduce antimicrobial resistance (AMR), which can be caused by the overuse or abuse of medication like antibiotics, Singapore has set up a One Health AMR workgroup to provide a whole-of-government effort.
The workgroup will focus on three main areas - coordinating the surveillance activities of the problem across the different agencies, research on the factors that are related to it, and cooperating with overseas partners, as diseases may cross borders.
Senior Minister of State for Health and Transport Lam Pin Min, who announced this at a dialogue on Wednesday (Nov 1), said that this national strategic action plan sets the framework for Singapore's response to AMR.
"It is only a matter of time after the discovery of an antimicrobial and its introduction to market that a microorganism develops resistance to it, often fuelled by the overuse or abuse of these antimicrobials," said Dr Lam, who was speaking at the Public Health Thought Leadership Dialogue on Antimicrobial Resistance, held at the National University of Singapore.
Should antibiotics be no longer effective, then even simple infections could kill.
Dr Lam said the plan includes education of the public to raise awareness of the problem and what they can do to prevent it
It involves even children, with school activities to teach them about the risk of AMR.
"These can include simple steps such as maintaining good hand and personal hygiene, to more in-depth understanding of antibiotics and how they work," he said.
Aside from public education, the One Health agencies will also work with professionals and industry.
Dr Lam said three key elements in Singapore's fight is:
- Integration of the various agencies, such as the coordination of surveillance activities and data sharing across sectors. "This is important to improve our understanding of how AMR develops and circulates between humans, animals, food and the environment," he said.
- In-depth research to understand the complex factors influencing AMR. He highlighted a recent four-year study by clinicians and researchers of National University Health System, Singapore General Hospital and the Communicable Diseases Centre. The study focused on the use of novel diagnostics, infection control strategies and behavioural sciences to strengthen institutional and national capability in targeting drug-resistant bacteria.
- International collaboration. "Our domestic efforts must be complemented by cooperation and partnerships with our neighbours and international counterparts, where we learn from each other through the sharing of best practices in our collective effort to fight AMR," he said.
Joining hands to tackle superbugs
Salma Khalik Straits Times 6 Nov 17;
Singapore is a small country, so attempts to cut down on antimicrobial resistance (AMR) here are unlikely to impact the global scene. Furthermore, a lot of antimicrobials, antibiotics in particular, are used in farming, a sector that is pretty small here.
So, does having a national plan to combat AMR make sense? The answer is yes, for two good reasons.
The first is to remind people that many small efforts can together make a huge difference.
The other reason hits closer to home. By actively fighting the spread of superbugs, people here are protected to a greater extent.
While it might not be possible to stop a superbug from infecting people here, good hygiene practices, such as washing one's hands or covering the mouth when coughing and sneezing, can help stop it from spreading.
Singapore is also encouraging adult vaccines by allowing the use of Medisave for such purposes. Vaccines significantly reduce the incidence of infections. This, in turn, reduces the need to use antimicrobials to treat the ailment.
Also, farms can reduce the use of antibiotics in animals. Giving animals antibiotics to hasten their growth has led to an increase in resistance, and these resistant bugs can be passed from animals to people. People can also get infected by these bugs from the air, soil and water they come into contact with. It is therefore important to ensure that waste water from places that make or use antimicrobials do not carry trace amounts of the drugs.
There is a real risk that these could gradually build up resistance in bugs in the water, and in time, fish. This would impact the people who eat the fish.
That is why the Agri-Food and Veterinary Authority, the National Environment Agency and national water agency PUB have joined forces with the Health Ministry. This whole-of-government effort is a necessary move in the fight against AMR. And such a fight is necessary to protect our people.
Winning the fight against antimicrobial resistance
HSU LI YANG AND PAUL ANANTH TAMBYAH Today Online 7 Nov 17;
In a reflection of the complex nature of the problem, the workgroup that developed the plan included representatives from four government agencies – the Ministry of Health, Agri-Food and Veterinary Authority of Singapore, National Environment Agency and PUB.
The 24-page document broadly follows the World Health Organization’s Global Action Plan on AMR that was launched in 2015.
There are five core strategies aimed at limiting the spread of antimicrobial-resistant microbes and the hard to treat drug-resistant infections that they can cause.
These are education, surveillance, research, prevention of infection, and optimisation of antibiotic use.
The plan also outlines existing initiatives – largely driven by the four government agencies independently – and the gaps in each area.
But there are few details available at this point, as this is a “living document” and many of the proposed programmes are still work in progress.
The challenges posed by AMR are manifold and intricate.
The issue itself is invisible to and poorly understood by the majority of people.
Fundamentally, the ability of a microbe (bacteria, viruses, fungi and parasites) to develop or acquire resistance to the drugs used to kill them is a natural evolutionary phenomenon.
Many antibiotics are developed from natural occurring compounds used by microbes against each other – penicillin, famously, was isolated from a fungus – and thus the building blocks for resistance to these drugs already exist in the environment.
The widespread use of antibiotics in humans and agriculture artificially accelerates the process of resistance development.
Human activities, including delivery of complex healthcare to older and sicker patients, global travel and the industrial food production chain, facilitate the spread of antibiotic-resistant bacteria.
There is no “safe level” of antibiotic use below which AMR does not develop.
Yet, antibiotics are crucial to human and animal health, and excessive restriction of antibiotic use can potentially harm people - especially in the short term - even more than overuse of antibiotics in the long term.
Most people. including many health professionals, believe that hospitals and other healthcare institutions are the main generators and amplifiers of AMR.
This is a misconception. Antibiotic use in primary care has been shown to drive the development and spread of antibiotic-resistant bacteria in the community.
The volume of antibiotic use in agriculture and animal husbandry far exceeds that in humans. Antibiotic-resistant bacteria in the food chain as a result of such practices have caused infections and outbreaks in humans, either directly or through sharing of antibiotic resistance genes with human bacteria.
COMPETING INTERESTS
Perhaps surprising for a small and otherwise efficient country, we have an incomplete grasp of the scale of the problem of AMR in Singapore. The amount of antibiotics prescribed in private hospitals and collectively among general practitioners is not known, as is the prevalence of antibiotic-resistant bacteria in both private hospitals and community.
Traditionally, meat and other foodstuffs are not tested for the presence of antibiotic-resistant bacteria, but rather for antibiotic and other chemical residues in addition to specific bacteria that cause foodborne outbreaks, such as Salmonella species.
The socioeconomic impact of AMR specific to Singapore is also not well defined. Such knowledge is important for the calibration and future sustainability of intervention programmes.
Efforts at controlling the spread of antibiotic-resistant bacteria often run up against competing interests quickly. To name but a few:
1. When hospitals are full, separation of patients infected by antibiotic-resistant bacteria and implementation of infection prevention measures become challenging.
2. The use of rapid diagnostic tests for screening of inpatients for antibiotic-resistant bacteria incurs additional costs, and it is unclear at present who should bear them.
3. Prescribing is not separated from dispensing in Singapore. That is, doctors and vets can both prescribe drugs and sell them directly from their clinics. It is the professionalism of doctors and vets that is the primary barrier to profiteering from inappropriate antibiotic prescription. But patients and pet owners who demand antibiotics can chip away at this barrier.
4. The cost of meat obtained from animals raised without antibiotic growth promoters is higher, at least in this part of the world, and it is unclear if many people would willingly accept a cost difference of at least 20 per cent. It would also be difficult to officially verify claims that the animals were indeed raised “antibiotic growth promoter-free”. Or even truly “antibiotic-free”.
What will success in Singapore in our efforts to control antibiotic resistance look like?
Because microbes constantly evolve and new antibiotic-resistant bacteria will continue to emerge, there must always be effective, safe and relatively cheap antibiotics for infections in both humans and animals.
Many of the gains in cancer chemotherapy, transplant and other surgeries came about because of effective antibiotics that were available to treat patients with weakened immune systems.
AMR should not be allowed to significantly impact healthcare delivery or food safety. Whether we can slow the current trend towards increasing AMR is questionable, given the open nature of Singapore and dependence on global food production.
But Singapore cannot give up without trying, and it should do so in partnership with the region and internationally, as success in Singapore will depend on our neighbours being able to control AMR too.
The primary merit of Singapore’s national action plan, besides being a public declaration of resolve, is to highlight the interconnectedness of human and animal health and practices in the issue of AMR, and to focus the efforts of all stakeholder government agencies on this issue.
A long-term sustained effort is also explicitly spelled out. Bottom-up efforts from the various communities in human and animal health to promote education and awareness of antibiotics and AMR, research for better understanding of the issue, and private-public partnerships on interventions to control AMR will be necessary to match the top-down initiative that led to the development of the plan.
ABOUT THE AUTHORS:
Associate Professor Hsu Li Yang, who leads the Antimicrobial Resistance Programme at the NUS Saw Swee Hock School of Public Health, was a member of the workgroup that developed the National Strategic Action Plan. Professor Paul Ananth Tambyah is an infectious diseases physician and professor of medicine at the Yong Loo Lin School of Medicine.
