BACKGROUND :

An unprecedented acceleration in rates of antimicrobial resistance (AMR) has emerged as a defining 21st century global public health challenge. Absent interventions, wide ranging impacts are expected, from increasing clinical treatment failures and associated morbidity and pre-mature mortality to losses in livestock productivity and animal-source protein. AMR-associated economic losses—estimated at more than 3% of global economic output annually —are formidable. Enhanced by recent high level advocacy at global fora, including the United Nations General Assembly, World Health Assembly and G7 and G20 meetings, the full utilization of human, veterinary, and environmental health expertise, complemented by a diverse constituency of government, industry, academic, and international organization stakeholders, is making measurable progress toward addressing AMR. Originating from a Royal Thai Government-hosted Global Health Security Agenda forum in 2015 that defined gaps in a multi-sectoral approach to AMR, a Prince Mahidol Award Conference (PMAC) 2016 side meeting was convened to further identify drivers of AMR and priority areas in Asia for a focused near term approach, including: sub-optimal enforcement and compliance with existing globally adopted intergovernmental standards and guidelines in human and veterinary medicine; insufficient and inconsistent regulatory frameworks governing and monitoring antimicrobial use (AMU); low levels of AMR awareness and inadequate commitment to AMU stewardship; and absence of economic impact assessments and associated financial incentives for reduced usage. Following the PMAC 2016 side meeting, a second PMAC 2017 side meeting built upon these core issues, and identified in greater depth those priority areas where short term efforts will yield advancements in enhanced AMU stewardship, and strengthen efforts to minimize AMR, particularly in animal production sectors in Asia. These two PMAC side meetings have helped guide the development of the agenda for the overall PMAC 2018 conference, “Making the World Safe from the Threats of Emerging Infectious Diseases.” Subsequently, on June 20-21, 2017 in Washington, DC, the United States National Academies of Sciences, Engineering, and Medicine (NASEM) hosted a two-day public workshop that examined key areas in human, animal, and environmental health that contribute to the emergence and spread of AMR. Through a One Health approach, this workshop discussed gaps in these areas and presented the complexities of bridging the different sectors and disciplines to address this global threat. A key focus of the workshop was to explore immediate and short term actions and research needs that will have the greatest impact on reducing AMR. Over 100 workshop speakers and discussants contributed perspectives from government, academia, private, and nonprofit sectors. A proceedings of the presentations and discussions from the workshop will be prepared and published in accordance with NASEM’ institutional guidelines by December 2017. While the global community led by the Interagency Coordination Group (IACG) on Antimicrobial Resistance has made commendable progress on the identified priority areas, the fight ahead needs continued commitment and support of national and global actors. Building on the NASEM workshop and the PMAC 2016 and 2017 AMR side meetings, we propose a side event at PMAC 2018 to gather international experts across the One Health domains to further articulate a near term, action-oriented agenda to address AMR across multi-sectoral cross-cutting topics: 1) Surveillance under a One Health Approach; 2) Rational Use of Antimicrobials; and 3) Global Policy and Coordination. ••• 1. Setting the Context ••• Update on the development of the global response and discussion of the global landscape of AMR, including: • IACG current activities and look ahead to UNGA discussions on AMR in 2018/19 • PMAC2017 -2018 • Report on the “Call to Action” Berlin conference 2017 • Development of the “Global AMR R&D Hub” ••• 2. One Health Surveillance – How can it be developed and implemented? ••• There is a clear consensus on the imperative of ensuring that there is a truly ‘One Health’ approach to the delivery of a response to AMR, particularly the data that will inform the development of strategies and action plans, but this remains challenging in practice. With a particular focus on Asia and low and middle-income countries, what are the particular challenges of developing and implementing multisectoral surveillance efforts and what are the examples of best practices in the region? This session will include discussion on: • Reviewing current platforms for global, regional, and national tracking of geographic and temporal trends in resistance that aim to incorporate a One Health approach now or in the future, including WHO GLASS • Optimizing data acquisition, leveraging existing data and integrating data sources on AMR across human, agriculture, and environmental sources from both public and private sectors • Assessing and strengthening laboratory capacity for AMR detection and implementing standards for antimicrobial susceptibility testing in human and veterinary diagnostic laboratories as well as for environmental samples • Developing and implementing surveillance and monitoring systems for AMR/AMU that are harmonized for human and agricultural production settings ••• 3. Rational Use of Antimicrobials – How can it be achieved by implementing stewardship programs, policies on medicine use, and incentives for antimicrobials R&D? ••• Changing patient and provider behavior, animal health service provider and farmer behavior to improve patterns of antimicrobials prescription and consumption/use is one of the critical challenges to mitigate AMR across the One Health domains. This session will include presentations on: • Developing feedback and accountability mechanisms based on social and behavioral science principles for providers who prescribe antimicrobials • Applying accepted stewardship principles supported by appropriate incentives to optimize the judicious use of antimicrobials for both food and companion animals • Capturing best practices in agriculture in countries across Asia to promote prudent use of antimicrobials and identify those practices that need to be modified • Discussing how push funding initiatives (e.g. GARDP and CARB-X) and pull incentives can be married with improved access to new and existing antimicrobials; and, in turn, how widening access in low-income settings can be balanced with better stewardship and more prudent use of antimicrobials • Coordinating with the subregional groups (ASEAN, SAARC, SPC) on promoting and implementing prudent use of antimicrobials 4. Global Policy and Coordination– How can regional and global organizations support the implementation of AMR Multisectoral National Action Plans? While global and regional guidance have been produced to help curb antimicrobial resistance, many countries face challenges in developing and implementing effective national action plans. How can national action plans be successfully executed, and how can partnerships facilitate this? This session will include presentations on: • Examining to what extent global efforts on AMR are integrated with the work needed to achieve the Sustainable Development Goals and Universal Health Coverage • Understanding how the AMR agenda can be integrated and mainstreamed in the United Nations multi-sectoral work • Exploring the key challenges faced by policy makers (particularly in low- and middle-income countries) when implementing national action plans and best practices in tackling AMR and how this can be meaningfully supported by the UN-led process and the work of the IACG and WHO • Assessing how partnerships across sectors and with multiple stakeholders can help implementation of national action plans, and how will they be sustained • Identifying how to bridge gaps between low and middle-income countries and high-income countries, and between the global scientific and policymaking communities • Discussing governance mechanisms that would allow better coordination, accountability and monitoring of the progress achieved in the fight against AMR // ORGANIZERS // • U.S. NASEM Forum on Microbial Threats (Contact: Cecilia Mundaca Shah, Director of Forum on Microbial Threats) • USAID Headquarters and USAID Regional Development Mission - Asia and USAID/GH/ID (Contact: Daniel Schar and Sudarat Damrongwatanapokin) • Wellcome Trust (Contact: Jeremy Knox, Policy Lead, Drug-Resistant Infections) • Merck (Contact: Elizabeth Hermsen, Head of Global Antimicrobial Stewardship) • FAO (Contact: Katinka de Balogh, AMR focal point, FAO-RAP Thailand) Collaborators: • Management Agent for the Fleming Fund Grants Programme (Contact: Anthony Huszar, South East Asia Regional Coordinator) • US State Department Office of International Health and Biodefense (Contact: Jessica Petrillo and Oldadele Oguseitan) • UNICEF (Contact: Kumanan Rasanathan, Senior Advisor, Health Section)