WHO Global Strategy for

1 WHO/CDS/CSR/ : GENERALORIGINAL: ENGLISHWHO GlobalStrategy forContainmentof AntimicrobialResistanceWorld Health OrganizationWHO Global Strategy FOR CONTAINMENT OF antimicrobial RESISTANCEWHOC opies can be obtained from the CDS Information Resource CentreWorld Health Organization, 1211 Geneva 27, Switzerlandfax: +41 22 791 42 85 email: ENGLISHDISTRIBUTION: GENERALWHO GlobalStrategy forContainmentof AntimicrobialResistanceWorld Health OrganizationAcknowledgementsThe World Health Organization (WHO) wishes to acknowledge with gratitude the significant supportfrom the United States Agency for International Development (USAID) and additional assistance forthis work from the United Kingdom Department for International Development and the Ministry ofHealth, Labour and Welfare, Strategy is the product of collaborative efforts across WHO, particularly in the clusters of Commu-nicable Diseases, Health Technology and Pharmaceuticals, and Family and Community Health, withsignificant input from the staff at WHO Regional Offices and from many partners working with WHOworldwide.

2 In particular, WHO would like to acknowledge the important contributions made to thedrafting of the Strategy by Professor W Stamm, Professor ML Grayson, Professor L Nicolle and Dr MPowell, and the generosity of their respective institutions Infectious Diseases Department, HarborviewMedical Center, University of Washington, Seattle, USA; Infectious Diseases and Clinical Epidemiol-ogy Department, Monash Medical Centre, Monash University, Melbourne, Australia; Department ofInternal Medicine, University of Manitoba, Winnipeg, Canada; Medicines Control Agency, LondonUK that enabled them to spend time at also wishes to thank all those who participated and contributed their expertise in the consulta-tions (see Annex B) and those individuals and organizations that provided valuable comments on draftsof this document. World Health Organization 2001 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by theOrganization.

3 The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, butnot for sale or for use in conjunction with commercial views expressed in documents by named authors are solely the responsibility of those designations employed and the presentation of the material in this document, including tables and maps, do not imply theexpression of any opinion whatsoever on the part of the secretariat of the World Health Organization concerning the legal statusof any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dottedlines on maps represent approximate border lines for which there may not yet be full mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recom-mended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the namesof proprietary products are distinguished by initial capital by minimum graphicsPrinted in SwitzerlandContentsiiiExecutive Summary1 Summary of recommendations for intervention3 Part A.

4 Introduction and background9 Introduction11 antimicrobial resistance is a Global problem that needs urgent action11A Global problem calls for a Global response12 Implementation of the WHO Global Strategy13 Background15 What is antimicrobial resistance?15 Appropriate use of antimicrobials15 Surveillance of antimicrobial resistance15 The prevalence of resistance16 Conclusion16 Part B. Appropriate antimicrobial use and emerging resistance: issues and interventions19 Chapter 1. Patients and the general community21 Chapter 2. Prescribers and dispensers25 Chapter 3. Hospitals31 Chapter 4. Use of antimicrobials in food-producing animals37 Chapter 5. National governments and health systems41 Chapter 6. Drug and vaccine development47 Chapter 7. Pharmaceutical promotion51 Chapter 8. International aspects of containing antimicrobial resistance55 Part C. Implementation of the WHO Global Strategy61 Introduction63 Prioritization and implementation63 Implementation guidelines66 Monitoring outcomes66 Summary67 Recommendations for intervention68 Tables71 Suggested model framework for implementation of core interventions76 References83 Annexes93 Annex A.

5 National Action Plans95 Annex B. Participation in WHO Consultations961 Executive Summary Resistance is only just beginning to be consid-ered as a societal issue and, in economic terms, asa negative externality in the health care decisions to use antimicrobials (takenby the consumer alone or by the decision-makingcombination of health care worker and patient)often ignore the societal perspective and the per-spective of the health service. The World Health Assembly (WHA) Resolu-tion of 1998 (1) urged Member States to developmeasures to encourage appropriate and cost-effective use of antimicrobials, to prohibit the dis-pensing of antimicrobials without the prescriptionof a qualified health care professional, to improvepractices to prevent the spread of infection andthereby the spread of resistant pathogens, tostrengthen legislation to prevent the manufacture,sale and distribution of counterfeit antimicrobialsand the sale of antimicrobials on the informalmarket, and to reduce the use of antimicrobials infood-animal production.

6 Countries were also en-couraged to develop sustainable systems to detectresistant pathogens, to monitor volumes and pat-terns of use of antimicrobials and the impact ofcontrol measures. Since the WHA Resolution, many countrieshave expressed growing concern about the prob-lem of antimicrobial resistance and some havedeveloped national action plans to address theproblem. Despite the mass of literature on anti-microbial resistance, there is depressingly little onthe true costs of resistance and the effectiveness ofinterventions. Given this lack of data in the faceof a growing realization that actions need to betaken now to avert future disaster, the challenge iswhat to do and how to do it. The WHO Global Strategy for Containmentof antimicrobial Resistance addresses this chal-lenge. It provides a framework of interventions toslow the emergence and reduce the spread of anti-microbial-resistant microorganisms through: Deaths from acute respiratory infections,diarrhoeal diseases, measles, AIDS, malaria andtuberculosis account for more than 85% of themortality from infection worldwide.

7 Resistance tofirst-line drugs in most of the pathogens causingthese diseases ranges from zero to almost 100%.In some instances resistance to second- and third-line agents is seriously compromising treatmentoutcome. Added to this is the significant globalburden of resistant hospital-acquired infections,the emerging problems of antiviral resistance andthe increasing problems of drug resistance in theneglected parasitic diseases of poor and mar-ginalized populations. Resistance is not a new phenomenon; it wasrecognized early as a scientific curiosity and thenas a threat to effective treatment outcome. How-ever, the development of new families ofantimicrobials throughout the 1950s and 1960sand of modifications of these molecules throughthe 1970s and 1980s allowed us to believe that wecould always remain ahead of the pathogens. Bythe turn of the century this complacency had cometo haunt us. The pipeline of new drugs is runningdry and the incentives to develop new anti-microbials to address the Global problems of drugresistance are weak.

8 Resistance costs money, livelihoods and livesand threatens to undermine the effectiveness ofhealth delivery programmes. It has recently beendescribed as a threat to Global stability and na-tional security. A few studies have suggested thatresistant clones can be replaced by susceptible ones;in general, however, resistance is slow to reverseor is irreversible. antimicrobial use is the key driver of this selective pressure comes from acombination of overuse in many parts of the world,particularly for minor infections, misuse due tolack of access to appropriate treatment and under-use due to lack of financial support to completetreatment SUMMARYWHO Global Strategy FOR CONTAINMENT OF antimicrobial RESISTANCE WHO/CDS/CSR/ reducing the disease burden and the spreadof infection improving access to appropriate anti-microbials improving use of antimicrobials strengthening health systems and their sur-veillance capabilities enforcing regulations and legislation encouraging the development of appropri-ate new drugs and vaccines.

9 The Strategy highlights aspects of the contain-ment of resistance and the need for further researchdirected towards filling the existing gaps in knowl-edge. The Strategy is people-centred, with interven-tions directed towards the groups of people whoare involved in the problem and need to be partof the solution, prescribers and dispensers,veterinarians, consumers, policy-makers in hos-pitals, public health and agriculture, professionalsocieties and the pharmaceutical industry. The Strategy addresses antimicrobial resistancein general rather than through a disease-specificapproach, but is particularly focused on resistanceto antibacterial drugs. Much of the responsibility for implementationof the Strategy will fall on individual have a critical role to play in theprovision of public goods such as information, insurveillance, analysis of cost-effectiveness andcross-sectoral coordination. Given the complex nature of antimicrobial re-sistance, the Strategy necessarily contains a largenumber of recommendations for of the implementation of these in-terventions needs to be customized to nationalrealities.

10 To assist in this process an implementa-tion approach has been defined together withindicators for monitoring implementation andoutcomes. Recognition that the problem of resistanceexists and the creation of effective national inter-sectoral task forces are considered critical to thesuccess of implementation and monitoring ofinterventions. International interdisciplinary co-operation will also be essential. Improving antimicrobial use must be a keyaction in efforts to contain resistance. This requiresimproving access and changing behaviour; suchchanges take time. Containment will require significant strength-ening of the health systems in many countries andthe costs of implementation will not be negligi-ble. However, such costs must be weighed againstfuture costs averted by the containment of wide-spread antimicrobial OF RECOMMENDATIONS FOR INTERVENTIONS ummary of recommendationsfor Educate patients on simple measures thatmay reduce transmission of infection in thehousehold and community, such ashandwashing, food hygiene, Encourage appropriate and informedhealth care seeking Educate patients on suitable alternatives toantimicrobials for relief of symptoms anddiscourage patient self-initiation of treat-ment, except in specific PRESCRIBERS AND Educate all groups of prescribers and dis-pensers (including drug sellers) on the im-portance of appropriate antimicrobial useand containment of antimicrobial Educate all groups of prescribers on dis-ease prevention (including immunization)