Chapter 6
AMR education and research
6.1
This chapter examines the implementation of the JETACAR recommendations
in relation to education and research.
Education
6.2
JETACAR recommendations 15 to 17 urged the development of prudent use
codes of practice for antibiotics; regularly updated antibiotic use guidelines;
and the development of continuing educational programs on AMR by learned
(medical and veterinary) and professional societies. Recommendations 19 and 20,
which related to communications, also called for the development of an ongoing
education strategy to provide appropriately targeted information on AMR to
relevant professional bodies, stakeholders and the general public. The
Government supported these recommendations.
6.3
In relation to education, DoHA noted that the Government continues to
fund education programs and awareness campaigns to ensure that health
professionals, industry and the community are informed about antibiotic use.
Part of this program is undertaken by the National Prescribing Service NPS. Relevant
NPS activities include NPS News and Australia Prescriber journal; education on
targeted therapeutic programs; and consumer awareness campaigns as well as a
medicine line that consumer can call for information.[1]
6.4
DoHA also commented that the implementation of activities to address AMR
in Australia is a shared responsibility between governments, industries,
educators, health and veterinary professionals and the community.[2]
One group providing education in relation to antibiotic use is NSP
MedicineWise. NPS MedicineWise is currently running a campaign aimed at
reducing the prescription of antibiotics by 25 per cent over five years.
In April 2013, NPS launched a comprehensive campaign encouraging all
Australians to become 'antibiotic resistance fighters'.[3]
6.5
Two key communication campaigns were identified by DoHA: Antibiotic
Awareness Week; and the National Hand Hygiene Initiative. Antibiotic Awareness
Week is a global initiative that aims to raise awareness of the importance of
appropriate use of antibiotics in our hospitals and the community. The National
Hand Hygiene Initiative is delivered on behalf of the ACSQHC by Austin Health.
Its success has been recognised by the WHO which awarded the Initiative a 'Centre
of Excellence Award' in 2011. DoHA noted that in 2012, 569 hospitals
contributed data to the national initiative, comprising over 90 per cent of
public hospitals and over 50 per cent of private hospitals.[4]
6.6
In relation to the veterinary aspects of recommendations 15 to 17, DAFF stated
that it understands that these obligations have been, and continue to be,
fulfilled. For example, state and territory veterinary registration boards have
developed codes of practice and antibiotic use legislation is in place. In
addition, the AVA has published guidelines on the use of veterinary medicines
and policies on use of antimicrobial drugs.[5]
DAFF also noted that part of its website is dedicated to AMR issues associated
with food producing animals and food regulation and safety, and the Codex Adhoc
Intergovernmental Task Force on Antimicrobial Resistance.[6]
Concerns with the implementation of
recommendations relating to education
6.7
To successfully address the growth of AMR, effective education programs
will be required for medical professionals, veterinarians, the public sector
and the community. The implementation of the JETACAR recommendations relating
to education appears to have been progressed significantly. However, important issues
were raised in evidence including the effectiveness of education programs for
both practitioners and the community. For example, the committee was informed
that, in spite of the various education programs that had been conducted,
Australia's antibiotic usage remains high.[7]
Over the period 2005–06 to 2010–11, the aggregate antibiotic utilisation rates
for hospitals increased from around 930 to 985 daily defined doses per 1000
occupied bed days.[8]
In total, more than 22 million prescriptions for antibiotics are issued
each year.[9]
6.8
Submitters pointed to a number of significant areas where improvements
in education could be undertaken for both the community who seek antibiotics,
and practitioners who prescribe them.
6.9
Submitters argued that properly targeted education campaigns can have a
significant impact on prescribing rates. Friends of the Earth Australia pointed
to Scandinavia where more than a decade of education campaigns have contributed
to some of the lowest levels of superbugs in the world.[10]
NPS MedicineWise provided further detail on what has been achieved in
Scandinavia:
They have run a campaign and evaluation between 1994 and 2004
where they implemented surveillance and education. They saw a fall in prescriptions
from 536 prescriptions per thousand population per year down to 410
prescriptions per thousand per year. Those rates have been sustained. They
still have the lowest recorded levels of MRSA. So they are seeing the lowering
of prescribing translating into lower rates of the antibiotic resistant
infections.[11]
6.10
The ASA also emphasised the importance of ensuring that education
campaigns were sustained and coupled with audit and feedback on outcomes:
Research has demonstrated that the education campaigns and
guidelines are ineffective unless they are combined with sustained
interventions such as audit and feedback methods and/or a system where
proactive steps are taken to assist prescribing and interventions are made to
address poor performance.[12]
6.11
NPS MedicineWise concurred with the need for sustained education
programs and noted that each time it had undertaken an education campaign and implemented
a program to fight antibiotic resistance, evaluation has shown a decline in
antibiotic prescribing and a rise in community awareness. However, when the
campaigns have ceased, and in the absence of ongoing effort, some of the gains
have been lost.[13]
6.12
A common theme in the inquiry was the continuing overuse of antibiotics
in situations where they were not really needed, or where their effectiveness
was questionable, such as in the presence of viral infections. The CHF
indicated that their research showed that there is continued widespread
confusion about the efficacy of antibiotics in the treatment of viral and
bacterial infections.[14]
NPS MedicineWise also noted that consumers create significant demand for
antibiotics:
Recent NPS research found approximately 1 in 5 Australians
still expect to receive antibiotics when they visit their GP with a cough or
cold. This number increased to 76% – 3 in 4 people – if they had an ear, nose,
throat or chest infection, with 53% stating they would ask for a prescription
if one was not supplied by the GP. Consumers need to understand how antibiotics
work, which conditions they don't work for, and have a broader understanding of
the impact their treatment choices will have on the future of available
effective treatments for life threatening infections.[15]
6.13
Friends of the Earth, CHF and NPS MedicineWise argued that educating
consumers is vital if the usage rates of antibiotics are to be reduced.[16]
NPS MedicineWise concluded that to ensure that unnecessary prescribing rates
for antibiotics decline and consumers change their behaviour, ongoing education
campaigns are required:
Previous NPS research has shown during and immediately after
an antibiotic campaign has been run prescribing rates decline, however once the
campaign is out of mind antibiotic prescribing starts to increase. An
investment needs to be made in longer funded campaigns to achieve adequate
population exposure.[17]
6.14
In relation to practitioners, submitters commented on university
curricula and the attitudes to AMR and prescribing of those who working in the
community. Associate Professor Gottlieb highlighted gaps in the university
curricula for the education of medical professionals:
Where we have not kept up to date in an educational way is in
university curricula where there is very little mention of antimicrobials. Our
medical students, as an example, and I am sure those in other areas as well,
hardly hear about the problems of antimicrobial resistance. It is up to
individuals lecturers to mention it. They walk into hospitals, particularly
surgical trainees and so on, not having much of an idea of the scale of the
problem. If you do not get to people early then you may lose them.[18]
6.15
Similar concerns about training in the veterinary use of antibiotics were
raised by Professor Barton:
In veterinary schools although the microbiologists will
educate students about responsible antimicrobial use and the risks to animal
and human health from antimicrobial resistance, once the students get into the
clinical years this is dismissed as irrelevant by many of the clinician
veterinarians and the vets with whom they do work experience.[19]
6.16
As AMR is an international problem and thus resistance entering
Australia from other countries is a significant challenge, Associate Professor
Gottlieb noted that Australia could have an educational role internationally if
we are able to get our own house in order:
I see there is a huge problem in Asia—in South-East Asia,
China and so on. We can lead by example. There is no reason why Australia
cannot contribute to the dialogue that is out there. So I think we have an
educational role. But before we extend ourselves over there we have to be seen
to be doing the right thing here as well.[20]
Conclusions
6.17
The education recommendations appear to be one of the areas more
effectively addressed following JETACAR. However, much remains to be done,
given the continuing increases in antimicrobial usage and resistance in the
community with more than 22 million prescriptions for antibiotics being issued
each year.
6.18
One of the reasons for the high usage of antibiotics is the poor
understanding in the community of efficacy of antibiotics in the treatment of
viral and bacterial infections. JETACAR also noted that farmers who have
infected animals under veterinary care similarly have a poor understanding of
the use of antibiotics. In order to improve the understanding of the correct
use of antibiotics, education campaigns are required. The committee was
provided with examples of successful education campaigns which have led to the
increased awareness and reduction in antibiotic usage rates. However, to
achieve a real and sustained change in behaviour, education campaigns must be
well targeted and sustained.
6.19
Submitters also pointed to the lack of focus in both medical and
veterinary curricula and ongoing education for those already in the workforce.
6.20
The committee notes that as part of the proposed new national strategy
to address AMR, matters to be addressed include education and stewardship and
community and consumer campaigns. The committee welcomes the inclusion of these
matters in the national strategy. Further, the committee considers that
education campaigns under the national strategy must take account of some of
the issues identified in this inquiry, including:
- better linkages to monitoring and evaluation so the effectiveness
of education programs can be determined;
- ensuring that efforts are sustained, rather than being of a
start-stop nature;
- focussing on consistency of education and communication across
hospitals, healthcare facilities, general practitioners, veterinarians,
agriculture and the community;
- consistency of education within different levels in particular
disciplines, across disciplines (medicine and veterinary), and across
jurisdictions; and
- making contributions to education with Australia's trading
partners and neighbours.
Research and development
6.21
The JETACAR report observed that Australia had a high level of expertise
in the molecular biology of antibiotic resistance. However, the lack of a
centrally coordinated research facility or agenda had resulted in several
important areas needing attention, including alternatives to antibiotic growth promotants for animal production, alternatives to other antibiotic uses in animals and humans (including
vaccines), epidemiology of resistance (including molecular epidemiology and gene transfer
mechanisms), effects of intervention programs (for example, to reduce levels of prescribing and antibiotic use), clinical
efficacy and rapid diagnostic methods. JETACAR
recommended that all relevant research funding agencies give priority to
research into AMR.
6.22
The Government acknowledged that research into the areas identified by
JETACAR played an important and necessary role in controlling the emergence and
impact of antibiotic resistance. The Government also acknowledged that
Australia had access to research being undertaken overseas which should be used
to guide Australian research priorities and assist in making evidence-based
policy decisions.[21]
6.23
DoHA provided information on NHMRC research funding relating to AMR and
noted that it has increased dramatically over the last ten years. In 2002,
NHMRC invested $1.0 million in AMR research across 13 grants. By 2012, this
amount had grown nine-fold to $9.7 million across 65 grants (forecast
expenditure). The NHMRC's Strategic Plan (2010–2012) identified Planning for emerging infectious
disease threats
(including AMR) as a strategic research priority. The Strategic Plan
for 2012–2015 will continue funding for AMR research.
6.24
DoHA also noted that in 2012, NHMRC launched the Research Translation
Faculty, a major strategic initiative for health and medical research
translation in Australia and commented that 'this initiative will support more
effective and accelerated translation of health and medical research into
improved policy and practice in Australia...AMR is one of the health issues that
will be considered for action by the Faculty during the current NHMRC
triennium, 2013–2015.'[22]
6.25
One program funded by the NHMRC is the Centre for Research Excellence in
Minimising Antibiotic Resistance in Acute Respiratory Infections. This program is
investigating issue including side-effects of antibiotics, the extent of
benefits of antibiotics for acute respiratory infections, changes in
prescribing practice and whether changes to packaging can improve the use of
antibiotics.[23]
6.26
Research is also undertaken by industry associations. This research has
been conducted on molecular diagnostic tools, innate immune systems, predisposing
factors, capabilities to investigate AMR in the red meat supply chain, chicken
meat programs such as enhancing bird performance, antibiotic replacement, and
AMR in pork.[24]
The committee was also informed that some industry research investigating AMR
in red meat had informed the conduct of subsequent government studies:
This research demonstrated, for the industry, the low level
of resistant bacteria in animals and in meat, well before the DAFF and DoHA
reports were released. In fact, industry funding developed capability that was
utilised to perform the work presented in the DoHA report and provided a
valuable insight into how to conduct the study. A contract has been entered
into for the conduct of a survey to produce new data on antibiotic resistant
bacteria in cattle. This study will be comparable to the earlier studies and
also collect data of interest to current concerns. The medical community is
being consulted about the details of this survey.[25]
6.27
The CHF concluded that much has been done to advance the research
envisaged in recommendation 18, and that 'research into antimicrobial
resistance itself has largely been recognised as a priority'.[26]
Concerns with the implementation of recommendations relating to research
6.28
Not all submitters supported the view that the AMR research program
responds comprehensively to the JETACAR recommendation. The ASM, for example,
lamented the failure to develop a comprehensive research agenda, although it
acknowledged that there had been initial flurry of activity in the research
sphere following the release of the JETACAR report. This activity included
support for research in a variety of agricultural pursuits by the Rural
Industries Research and Development Corporation.[27]
6.29
However, both ASM and the ASA noted that the NHMRC's attempt to
establish a targeted AMR management research agenda has been unsuccessful
despite the Commonwealth in its response to JETACAR acknowledging that research
plays an important and necessary role in controlling the emergence and impact
of AMR. Similarly, a bid for a Cooperative Research Centre into Antimicrobial
Resistance Management was not supported.[28]
6.30
While the recent NHMRC funding for a centre for clinical research
excellence at Bond University to investigate AMR was viewed as a positive step,
other submitters noted that generally, there is a lack of funding for AMR.[29]
Professor Barton commented that there is little funding for AMR research from
the NHMRC and argued that this was an outcome of the NHMRC's focus on esoteric
science rather than on practical measures to address AMR. Professor Barton also
noted a limited level of interest from industry on AMR research:
I was the beneficiary of funding from RIRDC Chicken Meat, the
then Pig Research and Development Corporation and then Australian Pork Limited
to carry out some baseline studies and the Meat and Livestock Australia have
funded some work in the beef feed lot industries. Other industry funding bodies
appear to have no interest – some respond that antimicrobial resistance is a
public health issue and so research should be funded by the NHMRC.[30]
6.31
Professor Cooper also commented on the NHMRC research priorities and argued
that the low level of AMR research funding does not reflect that rates of
deaths caused by AMR:
In the last round for the NHMRC less than 2 per cent of the
budget was allocated to infectious disease research. Of that, going through the
grants awarded, only $2.6 million was awarded to antibiotic research and new
antibiotics. That is a very, very small number. We estimate that the cost to
the Australian economy is definitely in the hundreds of millions and may be
even higher. The amount of research funding available for antibiotics is less
than 1 per cent of the cost to the economy. That doesn't make sense. So we need
to review our research priorities in this area.[31]
6.32
Similarly, the AVA commented that the funding for antimicrobial research
is 'well below what the subject demands' and may indicate that this 'area has
not attracted the priority it deserves by governments and other funding
agencies'.[32]
6.33
The ASM suggested that the apparent disinterest in adopting a
comprehensive research agenda may have been the result of the Government's
response to recommendation 18 which 'could be read to imply that Australia
could just adopt the outcomes of research that was conducted overseas'. The ASM
stated that such a view 'totally ignored the unique conditions present in
Australia in both human health and agriculture'.[33]
6.34
Submitters called for a greater emphasis on AMR research and suggested a
number of ways to achieve this.[34]
The ASM recommended that an inter-sectorial group be re-established to
re-formulate a strategic research plan for AMR management in Australia.[35]
The AVA submitted that it would be very useful to have a central register of
research on AMR across human and animal species that included some assessment
of the effectiveness of the research being carried out.[36]
6.35
The ASA suggested that a new approach is needed with a focus on
epidemiology in both human and animal settings and on effective interventions
for the public sectors, focusing on education and behavioural change. The ASA
went on to comment:
Despite funding by the NHMRC and other bodies for basic
science research on microbiology, many essential aspects, such as research into
educational interventions required to combat antibiotic resistance do not find
a ready place in existing project grant structures.[37]
6.36
The PHAA also advocated for research directions that include
epidemiological studies and translation of basic research findings into
practical applications for prevention diagnosis and treatment of resistant
infections.[38]
Professor Rood noted that difficulties of accessing funding for epidemiology
research.[39]
6.37
In addition, the Antimicrobial Resistance Summit in 2011 addressed
research and called for 'a major research effort targeting all aspects of this
threat to human and animal health in terms of causes, consequences, new
antimicrobial agents, and prevention strategies'.[40]
Another suggestion put to the committee was that a single independent body
responsible for managing AMR be established and that its role include funding
and influencing the AMR research agenda.[41]
6.38
A further area of research raised by submitters was the development of
new antibiotics. As noted in chapter 1, there had been a significant decline in
research and development by large pharmaceutical companies. Submitters argued
that there are opportunities for small pharmaceutical companies, working in
conjunction with researchers, to look at developing new antimicrobials to a
point where they can be drawn to the attention of large companies. Professor
Rood saw this as a model for the future with advantages in terms of fewer
constraints, smaller pilots and many more targets being identified and worked
on.[42]
6.39
The ASM supported this approach. However, only limited resources are
currently being allocated through standard competitive granting schemes even
though members of ASM are key players in driving innovative drug development on
both the national and international stage. The ASM recommended the formation of
an Innovation in Antimicrobials Research Steering Committee to formulate
strategic funding initiatives to drive research leading to antimicrobials
development and implementation.[43]
6.40
In addition, Professor Cooper suggested that, to support the antibiotic
pipeline, regulatory reform was required as well as funding to support
expensive stages of research and development. Professor Cooper also stated that
there was a requirement for training academic researchers in the science of
drug discovery. Exchanges with industry could be supported by government
funding with academics allowed, even encouraged, to spend time with partner
pharmaceutical companies and 'learn by doing'.[44]
Conclusions
6.41
While the DoHA and DAFF argued that significant funding has been provided
for AMR research, evidence was received that there is poor funding of research for
AMR issues. The committee considers that the lack of emphasis on research in
relation to AMR does not reflect the extent of the present problem or the
potential problems facing the health sector and the Australian community.
6.42
Much of the research agenda proposed by JETACAR remains to be undertaken,
in areas such as epidemiology of resistance (including molecular epidemiology and gene transfer mechanisms), effects of intervention programs (e.g. to reduce levels of prescribing
and antibiotic use), clinical efficacy
and rapid diagnostic methods. In
particular the epidemiological research needed to understand AMR trends has not
been delivered. The resulting lack of epidemiological information has made it
much more difficult to implement and evaluate policies to effectively address
AMR.
6.43
The committee acknowledges that some research has been sponsored by food
animal industries, but further research needs to be undertaken into alternatives to antibiotic growth promotants for animal production and alternatives to other antibiotic uses in animals and humans (including vaccines).
6.44
Another significant research issue brought to the committee's attention
during the inquiry is the dwindling supply of new antimicrobials. A large
portion of the research on new antibiotics has been undertaken by
pharmaceutical companies in the past. However, that is no longer the case,
partly as a result funding of changes that have dramatically reduced the profitability
for new antimicrobials as opposed to treatments for other conditions. Evidence
indicated that there are ways Australian research can make significant
contributions to the development of new antibiotics, including partnerships
between researches and companies focussing on a larger number of smaller trials.
6.45
The committee notes that research into AMR and its prevention were to be
included the work of AMR Standing Committee on a national strategy and that the
Australian Antimicrobial Resistance Prevention and Containment Steering Group
is to provide advice on future research priorities for Australia in relation to
AMR. The committee welcomes this recognition of the importance of research in
addressing AMR issues.
Recommendation 10
6.46
The committee recommends that the Commonwealth consider measures to
support research into strategies to deal with antimicrobial resistance,
including research into new antibiotics and consideration of antimicrobial
resistance being designated a National Research Priority Area.
Senator Scott
Ryan
Chair
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