Dear Reader. Anti-infectives and Resistances: Addressing health risks effectively

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1 Northern Dimension Partnership in Public Health and Social Well-being A partnership committed to achieving tangible results e-newsletter Issue 2/2014 Contents Anti-infectives and Resistances: Addressing health risks effectively 1 NDPHS launches project against antimicrobial resistance 2 NDPHS project on HIV prevention delivers first results 3 Priority Area Health second best in attracting EUSBSR seed money 4 Russia adopts the Potential years of life lost indicator following NDPHS advice 4 Introducing the NDPHS intern 5 Dear Reader This issue of the NDPHS e-newsletter focusses on the growing antimicrobial resistance that poses an increasingly serious threat to public health. A new NDPHS project, which addresses this issue and has been recently launched, is presented to that end. You will also find an update on the progress made by the NDPHS project on the HIV prevention among youth at high risk, and learn about the successful efforts of EUSBSR Priority Area Health stakeholders in attracting seed money funding. For those interested in the project-to-policy efforts, we present an article how ideas and advice provided by the NDPHS Expert Group on Non-Communicable Diseases have been followed in practice on a country level. Enjoy reading! Anti-infectives and Resistances: Addressing health risks effectively The development of antibiotics is one of the greatest medical achievements as it has lowered the risk of deadly infectious diseases to a previously unimaginable extent. For all spectacular successes, however, we have come to realize that infectious diseases have lost none of their significance. WHO data reveal that they are still among the main causes of death worldwide. In the industrialised countries, it is mainly elderly, chronically ill persons and individuals infected secondary to medical treatments or critical illness, who are susceptible to severe and fatal infections. Risks are high, particularly, following Photo: thinkstock.com extensive surgery, transplantations, oncological treatment and in ICU settings. By their very nature, many modern medical interventions carry an infection risk and would be impossible to perform on a routine basis, without effective antibiotics. Today, antibiotics are among the most widely used drugs in health care. This is due to both the advances in modern medicine that result in a growing number of individuals at elevated risk of infection, and the misuse and overuse of antibiotics that is mostly due to a lack of knowledge or unreasonable expectations regarding their effectiveness. The direct consequence of this excessive antibiotics use is the pathogens increasing resistance to the currently available substances. The phenomenon of antibiotic resistance is neither new nor unexpected. It comes from the ability of microorganisms to protect themselves from the toxic effects of antibiotics through their natural genetic makeup, through mutation or through sharing resistanceconferring genes with other microbes. Currently, a major cause for concern is the increasing global incidence and swift spread of multidrug resistant strains that have the potential to seriously compromise treatment options and, as such, pose a growing risk for patients and the health 2

2 Anti-infectives and Resistances: Addressing health risks effectively 1 care system overall. The foregoing is compounded by the fact that next to no new antibiotics have been brought to market in recent years, and this is not likely to change in the foreseeable future. What is particularly alarming, though, is the recent appearance of gram-negative pathogens that are resistant to almost all, or indeed all, currently available anti-infectives. If this development continues unchecked, several infectious diseases will no longer be amenable to treatment with antibiotics, i.e. whole sectors of medicine will be set back into the pre-antibiotic era. In the face of this growing threat to patients and the health care system overall, effective measures and coordinated action are urgently needed to contain and control it. With antibiotic treatment, more than any other medication regime, the implications for society at large have a major role to play - individual therapeutic benefit must be weighed against the potential harm to society (resistances). Specifically, this requires activities across the following key areas: Communication and deepening of knowledge about the antibiotics mode of action and the emergence and spread of resistances; Changing and enhancing antibiotic prescribing practice; Diagnostic microbiology; Surveillance of infectious agents, resistance data and data on antibiotic use; Infection prevention; Promotion of networking structures and public awareness campaigns. Antibiotics remain the cornerstone of each modern health care system. However, the cavalier use of this precious resource has caused global resistances to emerge that compromises the effectiveness of these drugs. It will take extraordinary efforts to both ensure optimum treatment outcomes for each individual patient and to safeguard a constant level of effectiveness for future patients. This article is based on a position paper of the Anti-infectives, Resistances and Therapy (ART) Commission at the Robert Koch Institute, dated 7 May You can read the whole paper in German at Positionspapier/Positionspapier_node.html. An unauthorised translation to English can be downloaded from ndphs.org/?doc,anti-infectives_and_resistances_addressing_ health_risks_effectively.pdf NDPHS launches project against antimicrobial resistance The NDPHS AMR Task Group facilitated the development of a new 3-year project called NoDARS (Northern Dimension Antibiotic Resistance Study). The project, which is co-financed by the European Union, aims to investigate the levels of specified antimicrobial resistance at participating sites in Germany, Latvia, Norway, Sweden, Poland, Russia and, possibly, Finland. It aims to determine resistance levels in Escherichia coli bacteria from uncomplicated urinary tract infections (UTIs) collected from patients attending primary health care centers. It will also examine the Photo: thinkstock.com penetration of antimicrobial resistance in society by determining the carriage rate of ESBL- and carbapenemase-producing E. coli and Klebsiellae. pneumoniae in community carriers. The results will be used to evaluate and suggest changes to current national treatment recommendations and antimicrobial resistance strategies. The objective is that treatment recommendations for uncomplicated UTIs be based on actual resistance levels to a larger extent. This is to avoid unnecessary use of broad-spectrum antibiotics for empirical treatment with the long-term goal of slowing down the development and dissemination of antibiotic resistance. As agreed during the recently held meeting of the Project Steering Group, two workshops will be arranged by the Public Health Agency of Sweden during the first half of 2015 to discuss in detail the study set up and methodology. By employing common strategies, methods and goals, it will be possible to compare data between the participating sites, which also supports the ongoing global surveillance 3 initiatives. 2

3 NDPHS launches project against antimicrobial resistance 2 The is the lead partner of the project and the Public Health Agency of Sweden, the Institute of Antimicrobial Chemotherapy of Smolensk State Medical Academy (Russia), the Pauls Stradins Clinical University Hospital (Latvia), the Norwegian Institute of Public Health, the Institute of Occupational Medicine and Environmental Health (Poland) and the Robert Koch Institute (Germany) are co-partners of the project. Discussions are held with the University of Turku, which has expressed its wish to join the project. Read more at project,1468 or contact the or the undersigned if you would like to receive further information. Karin Tegmark Wisell Sofia Ny The Public Health Agency of Sweden NDPHS project on HIV prevention delivers first results The -led and EU co-financed project Building capacity in prevention of HIV and associated infections among youth at high risk in the Northern Dimension area is making a good progress. During the first year of its implementation a needs assessment of young people at risk in HIV and AI prevention programmes was conducted, best practices were collected and, finally, stakeholders were trained. The needs assessment has confirmed that there are a lot of factors increasing the risk of getting HIV and AI of young people experimenting with drugs, migrant youth and adolescents and young people involved or at high risk of being involved into commercial sexual exploitation in the project locations, i.e., St. Petersburg, Kaliningrad, Riga and Warsaw. Thus, the survey conducted among children Photo: Veronika Odinokova and young people experimenting with drugs (n=1596, years old, mostly vocational schools students, in Warsaw also clients of low threshold services) has confirmed that main the risks of getting HIV and AI in that group are related to drug abuse, risky sexual behaviour, insufficient knowledge on HIV and insufficient coverage by prevention programmes. A lot of good practices in the field of HIV and AI prevention among children and young people at high risk of getting HIV and AI have been collected within the project. Nevertheless, the following main challenges have been identified for the project countries: (i) lack of prevention programs which would include effectiveness estimation component conducted in accordance with academic standards; (ii) lack of long-term prevention programmes (most of them are implemented by NGOs and, thus, are small-scaled, project based, sporadic and not stable); and (iii) none of the best practices identified within the project was published in a peer-reviewed journal. That is why during the training for stakeholders from Kaliningrad, St. Petersburg, Warsaw and Riga conducted within the project, recently held in St. Petersburg, special attention was paid not only to the exchange of best practices in the field of HIV and AI prevention among children and young people at high risk of getting HIV and AI, but also to the issue of estimation of the effectiveness of HIV and AI prevention programmes. Read more at view,project,1467 or contact the or the undersigned if you would like to receive further information. Dr. Olga Kolpakova Regional NGO Stellit 3

4 Priority Area Health second best in attracting EUSBSR seed money The success of the Priority Area (PA) Health in securing seed money for project ideas continues. Within the EU Strategy for the Baltic Sea Region (EUSBSR) Seed Money Facility, Health is still the second most funded Priority Area after the outcome of the third and last round of project approvals has been announced last October. Among the five health projects awarded funding is the most recently approved Rural Medicine Goes to Town project, an initiative by the Västerbotten Country Council, Rural Medicine Center in Storuman (Sweden), the Hospital of Southern Jutland (Denmark), the University of Skoevde (Sweden) and the National Centre of Rural Medicine (Norway). The project seeks to make the expertise developed in rural hospitals for dealing with a rapidly aging population available for urban contexts. It is based on the conviction that remote hospitals in sparsely populated areas with a high percentage of elderly patients have developed efficient and cost effective primary and emergency care methodologies, skills and organisational structures to address the demographic challenges they face. Through cooperation between rural and urban institution and across borders, this knowledge should be made available and beneficial for all participants and other organsiations in the Baltic Sea Region and beyond. The Rural Medicine Goes to Town project application received a letter of support from the NDPHS Secretariat, because of its promise to contribute to achieving the objective of fighting health inequalities through the improvement of primary healthcare. With this project being granted 42,415, the EUSBSR PA Health has, altogether, been granted 212,300 from the EUSBSR Seed Money Facility. Russia adopts the Potential years of life lost indicator following NDPHS advice In October 2014, the Federal Public Health Institute in Moscow has, with approval of the Department of Monitoring, Analysis and Strategic Development Healthcare of the Ministry of Health/Russian Federation, prepared and distributed Methodological recommendations for the use of Potential PYLL Years of Life Lost (PYLL) indicator to define priority health problems of the Russian population at federal, regional and local levels to all 83 administrative regions in Russia. The methodology is based on the results of the Saint Petersburg Healthier People project , a NDPHS pilot project MORTALITY 4 FEMALE MALE 53,3 % 45,2 % 68,5 % 59,8 % Source: St. Petersburg Center for Medical Information and Analysis (MIAC/ Dr. Igor Krasilnikov),

5 Russia adopts the Potential years of life lost indicator following NDPHS advice 4 facilitated by the Non-communicable diseases (NCD) and effectiveness of the prevention of infectious diseases, Expert Group, which successfully analysed the preventable such as HIV/AIDS, tuberculosis and life threatening infections causes of premature mortality and helped implement a complicated by antimicrobial resistance. For example, in Finland, Norway and Sweden premature deaths caused by such Health in all Policies approach in this metropolitan city. The success of the project, which was supported financially by the illnesses are practically zero. PYLL is especially useful in detecting causes, which kill young people, such as AIDS in Russia. In EU and the Nordic Council of Ministers, convinced the Russian Federal Ministry of Health to spread the methodology Saint Petersburg, the PYLL-analysis has revealed that infectious throughout the country. Using the PYLL-indicator will boost diseases caused 6.6% of all preventable deaths among women, whereas their infectious disease mortality is only 3.9%. The the Russian efforts to fight communicable and non-communicable diseases more effectively. premature losses of women due to infectious diseases in St. On October 2014, the Federal Public Health Institute Petersburg are, therefore, bigger than those associated with organized in Moscow a high level conference where practically all Russian regions were represented. Among the speak- breast cancer. Respective figures for men are 7.9% vs. 5.0%. None of the NDPHS member countries is systematically using PYLL-methodology to facilitate management of ers were also guests from WHO-EURO, the NDPHS NCD Expert Group, and public health experts from the Alberta University change. Russia is now in the process of taking the lead in this in Edmonton, Canada. The Federal Public Health Institute currently identifies 3-6 oblasts/regions, which will analyse their field. However, the provision of analytical information about important infectious diseases, in addition to NCDs, needs to preventable causes of premature death objectively and formulate, implement and monitor their health strategies by using the PYLL-indicator. be further developed and reported. Better monitoring of life lost due to fatal occupational accidents, traffic injuries and suicides is also essential. Although most preventable deaths (ca. 80%) are caused by lifestyle related, non-communicable diseases, the PYLLindicator is also very good in demonstrating the importance Dmitry Titkov, NCD Expert Group Mikko Vienonen, NCD-EG Chair ITA Introducing the NDPHS intern I have been interning at the as a fellow of the Carlo Schmid Programme for Internship in International Organisations and EU-Institutions since September My time here has already been a great learning experience and a valuable insight into the area of health governance at an international level. Previously, I completed an Erasmus Mundus Master in Global Studies at the London School of Economics and the University of Roskilde. During this time, I developed a particular interest in public health and epidemiology. My thesis examined the obstacles intra-european migrants without insurance cover face, when trying to access health care services in Germany. I concluded that a discordance between European and national legislation causes severe difficulties for the vulnerable group of non-insured migrants, even those who are citizens of the European Union. It results in many of them not being able to receive any other care than emergency treatment, depriving them of their human right to health. The engagement with this topic made me understand the need for cross-border cooperation on social issues and the importance of a health in all policies approach. Working with the NDPHS showed me how such cooperation works in practice, how ideas for improvements can be realised, but also how complex their implementation can be. I have no doubt that this knowledge and the skills I develop here will be an asset for my future professional development and I look very much forward to my remaining time at the Secretariat. Wiebke Seemann, Germany The NDPHS e-newsletter is published by the Northern Dimension Partnership in Public Health and Social Wellbeing (NDPHS) Secretariat in Stockholm, Sweden. It is published bi-annually and is available in electronic format through direct mailing to subscribers, and on the NDPHS website, where you can also subscribe to it ( The newsletter may be freely reproduced and reprinted, provided that the source is cited. While the contributions received for this issue are highly appreciated, it should be noted that the views and opinions expressed by the contributors do not necessarily reflect those of the publisher. We plan to publish the next issue in spring Contributions are encouraged and welcome. If you are interested, please contact us at the. P.O. Box Stockholm, Sweden secretariat@ndphs.org Website: Visiting addres: Slussplan Stockholm 5