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9/14/17
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LunchPLEASERETURNBY1:30
Panel3
DowehaveeffectivestewardshipinthehumanandveterinarysectorsinCanada?
DavidPatrickScottMcEwenAllisonMcGeerJohnPrescott
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DOWEHAVEEFFECTIVESTEWARDSHIPINTHEHUMANANDVETERINARYSECTORS
INCANADA?PANEL3: DAVIDMPATRICK
SPEAKINGFORTHEPOINT(HUMANHEALTH)
POINT:HUMANSECTORDavidM.Patrick
Antimicrobialstewardship“Coordinatedinterventionstopromote,improve,monitorandevaluatejudiciousantimicrobialusetopreservetheirfutureeffectiveness.”◦ Pan-CanadianFrameworkforAction
Must beconceptualizedecosystem-wide◦ HumanUse(FacilityandCommunity)◦ CompanionAnimalUse◦ AgriculturalUse◦ EnvironmentalContamination(Antibiotics,AROs,Rgenes)
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Yes- We’veMadeProgress
AHeterogeneousFederation
Welearnfromvariation.
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“Multi-facetedcommunicationinterventionsthattargetboththegeneralpublicandclinicianscan
reduceantibioticprescribinginhigh-incomecountries.”
ELCrossetal.JAntimicrob Chemother 72(4),975-987.2017Apr01
CanadaintheWorld:CommunityPrescribing
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CommunityPrescribing– BritishColumbiaPrescribingDown15%AntibioticDrugCostsby$53MBCPharmaCare Costsby$25M
BCPharmaNet
CanadaintheWorld:HospitalPrescribing
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Weseelargelystableandevendecliningresistancelevelsincommunitypathogens.
UseorResistanceReductionisonlyameanstoanend.It’saboutbetteroutcomes.
From: Impact of Infectious Disease Consultation on Quality of Care, Mortality, and Length of Stay in Staphylococcus aureus Bacteremia: Results From a Large Multicenter Cohort Study. Clin Infect Dis. 2015;60(10):1451-1461. doi:10.1093/cid/civ120
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Wenowneedtoscaleupwhatisalreadyworking.
DOWEHAVEEFFECTIVESTEWARDSHIPINTHEHUMANANDVETERINARYSECTORS
INCANADA?PANEL3: ALLISONJMCGEER
COUNTERPOINT(HUMANHEALTH)
POINT:HUMANSECTORDavidM.Patrick
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Yes- We’veMadeProgress
CanadaintheWorld:CommunityPrescribing
17.8
10.7
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Weseelargelystableandevendecliningresistancelevelsincommunitypathogens.
AntibioticresistanceOntario,2006-2015
PRESENTERNAME CAHSFORUMONINDIGENOUSHEALTHSEPTEMBER16,2016
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CPEincidence,CNISPhospitals
PRESENTERNAME CAHSFORUMONINDIGENOUSHEALTHSEPTEMBER16,2016
IncidenceofCPEinfectionbyCPETorontoandPeelRegion
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 20170
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Incide
ncepe
r100,000
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Whatwehavedone:• Identified(manyofthe)currentsurveillancesystemsrelatedtoAMRandcoordinateddata• DevelopedaFrameworkforAction(Aug2017)
Whatweneedtodo:• Identifythestructureofandbuildthenationalsurveillancesystemsthatweneed• Createandimplementanactionplan
PRESENTERNAME CAHSFORUMONINDIGENOUSHEALTHSEPTEMBER16,2016
AntimicrobialstewardshipinHumans
Reducing the Impact of
AMR
Transmissionprevention
Antimicrobial stewardship
Newantibiotics
Resistance and antimicrobial use surveillance
Alternatives toantibiotics
Other infection prevention
New diagnostics
Immunization
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DOWEHAVEEFFECTIVESTEWARDSHIPINTHEHUMANANDVETERINARYSECTORSINCANADA?PANEL3:SCOTTMCEWEN
POINT=YES:VETERINARYSECTOR
ScottMcEwen,UniversityofGuelph
Absolutely– ThingsareUnfoldingasTheyShould
Startedfromzero20yearsago– neededacompleteoverhaul
Humansafetyofveterinaryantimicrobials– until1990s,focusonresiduesinfoodfromanimals,NOTAMR(notbigprobleminanimals)
AMRstewardshipinanimalhealthishighlycomplex;numerousplayers
Context:The‘realworld’intheveterinarysectorisdominatedbybusinessconsiderations:◦ Veterinaryservicesmainlyfee-for-service;manycostsofAMstewardshippaidbyanimalowners
◦ Farmingalsoabusiness;mustbeefficientandresponsivetomarketforces
Panel3:ScottMcEwen,UniversityofGuelph POINT=YES:VETERINARYSECTOR
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HaveMadeRealProgress
Panel3:ScottMcEwen,UniversityofGuelph POINT=YES:VETERINARYSECTOR
•2002ReporttoHealthCanada
•38recommendations
•34implemented(2nolongerrelevant)
•Fullspectrumofissues:• Stewardship• Surveillance• Infectioncontrol• Research&Innovation
FederalRegulatoryChanges◦ Removalofgrowthpromotionclaimsformedicallyimportantantimicrobials(MIAs)
◦ PrescriptionstatusforallMIAs◦ Close“Ownuseimportation”and“API”loopholes◦ Mandatoryreportingofantimicrobialsalesvolumesbyspecies◦ Alternativestoantimicrobials– supportforinnovation,enablingregulation
◦ Bringsusintolinewithmajortradingpartners(US,Asia,Aust /NZ,Europe)
Panel3:ScottMcEwen,UniversityofGuelph POINT=YES:VETERINARYSECTOR
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VeterinaryOrganizations◦ CanadianVeterinaryMedicalAssociationisheavilyengagedwiththeissue;atoppriority◦ CanadianCouncilofVeterinaryRegistrarshasproposedprovincialandterritorialharmonizationofregulationsaroundveterinaryoversightofantimicrobials
◦ CVMAisfundedtoworkonupdatingprudentuseandstewardshipguidelinesinmajoranimalsectors
◦ SpecialtyveterinarygroupsareengagedwithAMRissues◦ CouncilofChiefVeterinaryOfficers,Provincialorganizations
Panel3:ScottMcEwen,UniversityofGuelph POINT=YES:VETERINARYSECTOR
PrivateSector/Industry◦ Heavyengagementofthemajorfarmgroupswiththeissuehaveledtoimportantchanges(e.g.CanadianpoultryindustrybanonCategoryIdrugsforprophylaxis)
◦ Infectioncontrol◦ Improvedanimalhealth,betterhusbandry,on-farmfoodsafetyassurance◦ Hugeeffortsatpathogencontrolinfoodindustry
◦ Marketforcesaredrivingchangesinantibioticusepracticesinfoodanimals
◦ CanadianAnimalHealthInstituteispromotingchange
Panel3:ScottMcEwen,UniversityofGuelph POINT=YES:VETERINARYSECTOR
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IntheGlobalContext– WePunchAboveourWeight
ExceededonlybynorthernEuropeancountries(wheretherearedifferencestorestoftheworldinAMgovernance,perceivedneedforaction,acceptanceof“top-down”interventions)
CanadiansImprovingStewardshipthroughGlobalEfforts:• WorldHealthOrganization(WHO)• WorldOrganizationforAnimalHealth(OIE)• CodexAlimentarius
Education&Expertise:• ConsiderableveterinarysectorAMR/stewardshipexpertisenationally
• CIPARSscientists• Universities(numerous(100?)CanadianMSc,PhD,DVSc theses)• Industry
Panel3:ScottMcEwen,UniversityofGuelph POINT=YES:VETERINARYSECTOR
DowehaveeffectivestewardshipinthehumanandveterinarysectorsinCanada?
COUNTERPOINT:VETERINARYSECTOR
JohnPrescott
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OBJECTIVES OF THE FORUM
Introduction
pan-CanadianFramework forAction
1.5YEARSBEHINDSCHEDULE
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pan-CanadianFramework forAction
PAN-CANADIANACTIONPLANHASSTILLTOBEWRITTEN
Atthemomentwedon’thaveeffectivestewardshipintheanimalhealthsectorNOMAP;NOPLAN;NOTIMING;NOCHECKLIST;NOEFFECTIVELEADERSHIPORCOORDINATIONSTRUCTURE
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Groups involved in
stewardship in
agriculture
Veterinary groups
Provinces, Canadian Council of VeterinaryRegistrars
CFIA; Agri-Food Canada)
Provinces, Council of Chief Veterinary Officers
Public Health Agency of Canada; Health Canada
Canadian Veterinary Medical Association
Canadian Animal Health Institute
Canadian farm groups; feed industry; nutritionists
Amajorfactorpreventingtimelydevelopmentofpan-Canadianstewardshipisalackofanagreedleadershiporcoordinationstructure
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Amajorfactorpreventingtimelydevelopmentofpan-CanadianstewardshipisalackofanagreedleadershiporcoordinationstructureWITHRESOURCEALLOCATION,REPORTINGSTRUCTURE,MEASUREMENT,EVIDENCEANDABILITYTOINTERVENE
Amongthemanyquestionsaboutapan-Canadianstewardshipplan
v Whohasoverallresponsibilityfordeveloping,monitoring,evaluatingandcommunicatingtheactionplan?
v WhataretherolesofPHAC,HealthCanada,AgricultureandAgriFood Canada,CanadianFoodinspectionAgency?
v HowwilltheyinteractwithprovincialMinistriesofAgriculture,veterinaryregulatoryauthorities?
v Howwillveterinaryregulationsrelatingtoantimicrobialusebeharmonizedacrosstheprovincesandterritories?
v Whatistheroadmapandwhatarethetimelines?
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Whatarethemetricsofsuccess?
Whatarethemetricsofsuccess?
IFYOUCAN’TMEASUREIT, YOUCAN’TMANAGEIT
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Considerablereductionandimprovementinantimicrobialuseandresistanceispossible
v Hollandhasachieved65%reductioninantimicrobialuseinanimalsinlast7years
v ReductionofantimicrobialresistanceinanimalcommensalE.colihasfollowedreduceduseinHolland
Antimicrobial stewardship
Practice guidelines
Pharmacokinetics, pharmacodynamics
Clinical microbiology
Resistance and use surveillance
Infection control
Leadership; regulation
Education
Owner compliance
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Antimicrobial stewardship
Practice guidelines
Pharmacokinetics, pharmacodynamics
Clinical microbiology
Resistance and use surveillance
Infection control
Leadership; regulation
Education
Owner compliance
GoodStewardshipPractice
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GoodStewardshipPractice
NEEDSEFFECTIVELEADERSHIPANDCOORDINATIONSTRUCTURE
“Inouropinion,thedevelopmentofapan-Canadianstrategywilltakemanyyears”
