UK regulator types on antimicrobial resistance in food

In 1969, the Swann report recommended strict oversight and restrictions on the use of antibiotics used in human medicine as growth promoters in agriculture. That was in the UK, and 37 years later, the UK Food Standards Agency has published a systematic review of the available evidence on antimicrobial resistance (AMR) in food. The review looked at research on the presence of AMR in bacteria in a number of different foods sold at retail.

fda-antibiotics-agricultureThe research has confirmed the need for extra surveillance of AMR in food at retail level, to support the wider programme of work currently underway across government to help reduce levels of AMR.

The study was produced by the Royal Veterinary College, on behalf of the Food Standards Agency, and looked at the areas where consumers are more likely to be exposed to AMR in bacteria from the food chain. Researchers examined published evidence between 1999 and 2016 for pork and poultry meat, dairy products, seafood and fresh produce sold in shops.

FSA action includes:

Working to encourage the adoption of clear transparent reporting standards that help consumers have access to and understand information about the responsible use of antibiotics in the food chain. 

Continued focus on improving the scientific evidence base relating to antimicrobial resistance in the food chain through supporting relevant research and improving surveillance. 

Setting up an independent group to advise us on responsible use of antibiotics in agriculture to support the above work.

Background

Antimicrobial resistance (AMR) is a major public health issue worldwide. It is a complex issue driven by a variety of interconnected factors enabling microorganisms to withstand antimicrobial treatments to which they were once susceptible. The overuse and/or misuse of antibiotics has been linked to increasing the emergence and spread of microorganisms which are resistant to them, rendering treatment ineffective and posing a risk to public health.

People can become exposed to AMR bacteria through a number of routes such as human-to-human spread, animals, through the environment and food chain. There is currently uncertainty around the contribution food makes to the problem of AMR and the types of AMR bacteria found in foods on retail sale in the UK. There is a need to consider the literature in this area to gain a better understanding of the potential risk to consumers through contaminated foods and also to identify the key evidence gaps.

Research Approach

The aim of this study was to assess the prevalence of antimicrobial resistant bacteria in retail pork, poultry meat, dairy products, seafood and fresh produce that could pose a risk to UK consumers. For this purpose a systematic review was undertaken following the PRISMA guidelines (Liberati et al., 2009) through which current existing evidence present in scientific databases and grey literature is collected and assessed. A protocol, which describes the methodology used, has been made accessible through the International Prospective Register of Systematic Reviews (PROSPERO). The protocol is available at http://www.york.ac.uk/crd/. Please search PROSPERO using registration number CRD42016033082.

ab-res-prudent-may-14Research questions were developed taking into consideration current evidence for relevant resistant foodborne pathogens and commensal bacteria observed in animals, food and humans in European countries published by the European Food Safety Authority (EFSA) (EFSA, 2015), feedback provided by experts and findings from scoping searches of the literature (i.e. PubMed).

Key recommendations: 

There is a need to standardise the selection of antimicrobials for antimicrobial susceptibility testing panels, harmonising criteria for assessment of resistance per bacteria/drug combination for surveillance purposes, using a standardised definition for multidrug resistance (MDR) and the adoption of random sampling and adequate study design for epidemiological studies.

Identification of a core set of relevant antimicrobials when developing and implementing prospective testing for surveillance systems for determination of AMR in the food chain.

Surveillance priorities could be set using a risk-based approach, taking into account the importance of antimicrobials used for treatment in both humans and animals, and continued surveillance of the incidence and emerging resistance (including MDR) in commensal bacteria (Enterococcus spp. and E. coli) should be encouraged.

Data on AMR bacteria from British and imported pork meat in the UK are limited and dated. Further research and surveillance efforts are needed to ascertain AMR levels in both foodborne and commensal bacteria in pork meat in the UK.

There is evidence of increasing levels of resistance to antimicrobials in foodborne bacteria (i.e., Campylobacter spp.) from poultry meat in the UK. Research and surveillance efforts should be continued to monitor AMR trends in both foodborne and commensal bacteria in British and imported chicken and poultry meats in the UK.

There is a lack of information on AMR bacteria in foods of animal origin other than meat at retail level. In recent years, there have been growing numbers of outbreaks associated with milk and dairy products (cheese, butter, yogurt), seafood (fish and shellfish) and fresh produce (fruit, vegetables and salads) at national and international levels but there is scarce, scattered evidence of resistance and MDR occurrence in foodborne and commensal bacteria in these food products and its implications for public health. These gaps should be addressed also using a risk-based approach following evidence of resistance in food items as well as the extent of expected consumer exposure using consumption and import volumes.

Data on antimicrobial usage in food-producing animals in the UK are important to explain the occurrence and dynamics of AMR, resistance genes and MDR phenotypes in a defined geographical area. More complete information should therefore be collected on the type of production system from which food samples originate to assess the impact of animal husbandry practices as risk factors for resistance.

There is a need for more studies to quantify the contribution of both domestic and imported foods to AMR occurrence. Information on country of origin for imported products should be collected.

Priorities should be set according to the importance of a food item in terms of exposure of consumers. Consumption data will be essential for assessing the risk of exposure of British consumers.

Finally, further research and surveillance are needed to establish and quantify the risk of transmission of AMR against critically important antimicrobials in organisms from foods of animal and non-animal origin) to humans.

A systematic review of AMR bacteria in pork, poultry, dairy products, seafood and fresh produce at UK retail level

August 2015-October 2016

Food Standards Agency

https://www.food.gov.uk/science/research/foodborneillness/b14programme/b14projlist/fs102127/a-systematic-review-of-amr-in-pork-and-poultry-dairy-products-seafood-and-fresh-produce

Health Canada proposes rules for veterinary drugs in livestock

John Cotter of Canadian Press reports the Canadian government is proposing new rules for veterinary drugs used in livestock as it works to reduce human health risks associated with resistance to antibiotics and other antimicrobials.

ab.prudentHealth Canada says the decreasing effectiveness of antimicrobials is having a significant impact on the government’s ability to protect Canadians from infectious diseases.

“The overuse and misuse of antimicrobials in animals is a contributing factor to the development and spread of AMR (antimicrobial-resistance),” reads a summary of the proposed rules.

“The development of antimicrobial-resistant pathogens in animals can pose serious risks to human health when they are transmitted as food-borne or water-borne contaminants. Antimicrobial-resistant infections are associated with a greater risk of death, more complex illnesses, longer hospital stays and higher treatment costs.”

The department says current regulations do not provide the necessary regulatory oversight to mitigate the risk.

The proposed changes would restrict the importation of some veterinary drugs used in livestock, require drug manufacturers to follow stricter rules regarding the quality of active ingredients and allow for increased monitoring of drug sales.

The department is seeking feedback on the proposals until Sept. 8.

Health Canada says the proposed changes will align Canada with policies in the United States and the European Union.

Statement of the American Society for Microbiology on the national strategy to combat antibiotic resistant bacteria

The American Society for Microbiology (ASM) congratulates the Obama Administration for its September 18 announced White House National Strategy for Combating Antibiotic Resistant Bacteria (CARB).   The strategy outlines bold steps to slow the public health threat of antibiotic resistant bacteria, including efforts to stimulate innovative research.   Importantly, the Strategy will establish a new Task Force for Combatting Antibiotic Resistant Bacteria which is directed to submit an action plan to the President by February 2015. This elevated attention at the highest level of government is needed because in the United States alone, antibiotic resistant bacteria cause 2 million infections a year and 23,000 deaths.

ab.res.prudent.may.14Innovative research is needed to discover new, effective antibiotics and to ensure existing antibiotics are properly targeted. Research will lead to innovative diagnostics to improve detection and tracking of pathogens, new vaccines targeted to drug resistant organisms and new antibiotics in partnership with private industry. Cutting edge genetic sequencing technologies used at point of care can enhance surveillance of antimicrobial resistance, enabling rapid tracking of genetic signatures and ensure rapid, accurate diagnosis and appropriate use of antibiotics saving lives and reducing resistance resulting from inappropriate treatment.  Because an estimated half of antibiotic prescriptions are inappropriate, encouraging the development of rapid, point of care tests is critical to identifying and tailoring treatment of resistant bacteria and minimizing the use of broad spectrum antibiotics.  

The National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) will play leading roles in the national response. The collaborative efforts of the these agencies will be extremely important to advance development and use of rapid diagnostic tests for identifying drug resistant infections. Enhanced regulatory processes and reduction in approval cycle time will be key. Reimbursement of new diagnostic tests will also be a major incentive for development of new diagnostics by the private sector. The recommended expansion of DNA sequencing capacity and collection of microbial genetic sequences in a centralized National Database of Resistant Pathogens will allow comparison of outbreak stains with the database collection, improving their control.

The emphasis on tracking resistance in humans, animals and food and promoting antibiotic stewardship across the food chain is vitally important, as well as minimizing antibiotic use for non-health purposes. The President’s Executive Order calls for work internationally, recognizing that efforts must be global to reduce the burden of antimicrobial resistance and its spread.

The National Strategy articulates national goals, priorities and specific objectives that provide an overarching framework for federal investments to combat antimicrobial disease. It will be extremely important that new and adequate funding is provided to accomplish this comprehensive agenda. The ASM appreciates the new initiatives and is committed to working with federal agencies and Congress as this ambitious agenda to address the threat of antimicrobial resistance gets underway.

Strengthening vet oversight of antimicrobial use in food animals: reducing antibiotics in meat — Part II

Ron Doering, former president of the Canadian Food Inspection Agency and current counsel in the Ottawa offices of Gowlings ([email protected]), reports with part II of his take on antimicrobiasl in food animal production:

While the medical commu­nity recognizes that the emergence and spread of antimicrobial resistance (AMR) in hu­mans is a potential disaster for humanity and that it is the overuse of antimicrobi­als in human medicine that is the largest contributor, there is a broad consensus that the use of antibiotics in animals contributes to the problem, though the scale is still unclear. This uncertainty is due mainly to a failure to adequately control and monitor the use. Health Canada (HC) lacks the authority to control and monitor use because the practice of veterinary medicine falls under provincial juris­diction. Recognizing that almost all practical efforts to reduce the level of antibiotics in meat depend on the more active participation of veterinarians, HC announced recently that it wanted “to develop options to strengthen the veterinary oversight of antimicrobial use in food animals.”

44755363What can veterinarians and their provincial regulatory licensing bodies do now to reduce the threat of AMR? Here are four suggestions:

1. Enhance awareness among members .

While the Canadian Veterinary Medical Association (CVMA) has developed vol­untary Prudent Use Guide­lines, I’m told that many vets are hardly aware of the issue and may not even know of the Guidelines. Concerned enough about this, Ontario’s regulatory body, the Col­lege of Veterinarians of Ontario, just an­nounced that it was launching a project to study the use of antibiotics among food animal veterinarians and to determine if they use the CVMA’s Guidelines in daily practice. Quebec requires a manda­tory day-long AMR program and a test. All provinces should follow Quebec and develop mandatory continuing education programs on antimicrobial stewardship.

2. Fill the regulatory gaps.

As long as vets continue to prescribe off label use and the use of Active Pharma­ceutical Ingredients (APIs) in production medicine, it’s impossible to know the level of antibiotic use. Own Use Importation (OUI) by animal owners is another avenue for which use information is un­available. As one recent report stressed: “The gap in reliable usage data makes it difficult to state with confidence which antimicrobials are used, in what quantities, and for what purposes.” The recent critical assessment by a group of experts, titled “Stewardship of antimicrobial drugs in animals in Canada: How are we doing in 2013?” (Canadian Veterinary Journal, March 2014), highlighted the absolute importance of improving Canada’s monitoring of antimicrobial usage.

3. Conflict of interest issue.

This issue has been flagged by several reports going back to the landmark McEwen Report of 2002. Veterinarians obtain income from the profitable sale of antimicrobials. Decoupling veterinary prescribing from dispensing raises several issues because the current veterinary prac­tice business model is based on an income stream from antimicro­bial sales. Veterinarians should lead a dialogue on this important issue that clearly needs closer examination.

ab.res.prudent.may.144. Antibiotics for disease prevention.

The real issue is not the use of antibiotics for growth promotion or the treating of disease, but whether they should continue to be used for disease prevention. While some antibiotics of very high importance to human health should only be used to treat infection, there are several arguments that some of high or medium importance to human health (what HC calls Category ll and lll, for example tetracyclines) should still, with closer veterinarian oversight, be used for disease prevention. Because major retailers, processors and consumers increasingly demand meat with “raised without antibiotic” claims, the marketplace is forcing changes in practice. But we mustn’t lose sight of the fact that while there are risks to using antimicrobials in animal production, there are also risks with non-use.

Two-thirds of animal diseases are zoo­notic, meaning the disease is transferable to humans. For this and other reasons, I have been a long-time proponent of strengthening the connections between human and animal medicine — the concept known as One Health. In this context, AMR represents an historic opportunity for vets to step up and provide greater leadership.