Interviews with the Experts
In this series we ask some of the leading experts in the field of antimicrobial resistance (AMR) and One Health for their take on progress, leadership and challenges.
Our latest interviewee is Dr. Muhammad Asaduzzaman, Research Fellow, Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo (UiO), Norway. Dr. Asaduzzaman is a member of One Health Research Group and Interdisciplinary Forum for Research on Antimicrobial resistance (INFRA) at UiO. Dr. Asad is also an active member of ‘Safer Pharma’ initiative of Healthcare Without Harm(HCWH), Europe and the Surveillance and Epidemiology of Drug-resistant Infections Consortium (SEDRIC).
Hello Dr Asaduzzaman. We are delighted to be able to interview you. Thank you. What have you been doing on AMR in the last few years?
Thanks to ‘Alliance To Save Our Antibiotics’ for contacting me. Though my research career is of more than 15 years, I started to work on One Health (OH) and AMR in 2014 when I was selected as the OH fellow for South Asia, a program funded by EU and governed by Massey University, New Zealand. After the fellowship with a Masters in OH and Biosecurity from Massey, I joined the ‘Laboratory of Food Safety and One Health’ at icddr,b and was pivoting my research in environmental dimension of AMR (I call it Planetary Health, PH-AMR) and OH-AMR surveillance until 2019. Then, I moved to University of Oslo (UiO) as a Research Fellow and am continuing my work in similar field but in more geographic locations e.g. EU, Ethiopia, Bangladesh.
During my tenure at icddr,b as Assistant Scientist and Research Fellow at UiO, my involvement in several mixed method OH-AMR projects in Bangladesh and Ethiopia is focused on integrated community surveillance of multi-drug resistant (MDR) pathogens in human, animals (poultry, cattle) and environments (soil, water, waste, air), transmission dynamics of community acquired MDR uropathogenic E.coli, co-occurrence of heavy metal and antibiotic resistance in community settings and qualitative investigation of the feasibility of digital OH-AMR surveillance in resource poor settings.
Besides my role as researcher, my passions are awareness building for OH and PH perspectives of AMR through science communication (writing in blogs/community forum/popular science articles), teaching of masters students and community engagement (I am the current Campus Ambassador of PHA, member of HCWH Europe, Regional coordinator in Europe for Next Generation
Global Health Security Network and country representative of HIFA ). My research outputs and community engagements are manifested in CRISTIN OR Researchgate.
Antibiotic resistance is increasingly referred to as the next global pandemic. A recent study published in The Lancet has estimated that 4.95 million people died of an antibiotic-resistant infection in 2019, and for 1.27 million of these people their deaths were attributable to the antibiotic resistance of the infection. Do you think current global actions will be sufficient to tackle a problem of this scale?
It is true that the global community is more aware than before on the topic of AMR. However, the awareness level is not same around the globe and the calls to action based on the awareness level are not sufficient. I can relate this scenario with Leon Festinger's classical Dissonance Theory which explains why many people seem to believe AMR as a big problem but with a confused mind. Therefore, the actions are not to the optimum level.
For example, if you consider the pharmaceutical industry, 70% of API (active pharmaceutical ingredients) come from China and most of the European states produce their antibiotics in India. The reason is entirely economic. In the meantime, antibiotic residue and pharma waste are the major pollutants in the Chinese and Indian aquatic environments. As my research interest is the community carriage of MDR pathogens, the high environmental selection pressure of superbugs from such notorious sources terrifies me. Only 4 out of 85 pharmaceutical companies from India and China signed the 'DAVOS Declaration’.
Most of the actions are taken in Europe and USA but what is the benefit if the sources are not rectified? Similar scenario exists in the animal farming practices in global south. In many countries, there is no legislation or no strict implementation of existing ones regarding the use of antibiotics in animal feed or as growth promoters. If we believe AMR as the next global pandemic, strict actions only in EU or USA will not work anymore, also evident in COVID-19.
One Health is an approach that recognizes that the health of people is closely connected to the health of animals and our shared environment. To what extent do you think that there is a need for a One Health approach to tackling the spread of antibiotic resistance?
In every aspect. To me, OH refers to far beyond the human-animal-environment interface. The classical OH approach is already criticised for neglecting the environmental component. Therefore, any multidisciplinary effort to combat a health problem seems to be an OH approach in my context. For AMR, there is no alternative to an integrated and multidisciplinary approach regarding sectors and geographic locations to mitigate it. The bottom line is-OH is a must which needs to be implemented globally at the same pace and direction. To do so, OH capacity building in the global south is the prerequisite.
Most of the scientific literature suggests that farm antibiotic use can contribute to higher levels of antibiotic resistance in human medicine. However, this issue remains controversial with some claiming there is no link. Do you believe that tackling the overuse of antibiotics in farming can contribute to controlling the spread of ABR in human infections?
I strongly believe so. The farm antibiotics can contribute to ABR in humans not only by consumption of antibiotic treated food but also by dissemination of farm waste and antibiotic residue in the nearby environments. Due to the horizontal gene transfer mediated ABR, such environments remain as a mixing hub/hotspots for ABR transmission in humans and animals. My recent article on ABR in aquatic environments adjacent to poultry value chain is a good example in favour of my statement.
Do you think the global growth in intensive livestock farming is contributing to higher levels of farm antibiotic use?
The high demand for protein since World War II, along with rapidly increasing intensive global farming practice and large industry around it, is closely related with the aggressive farm antibiotic use. You can get a clear idea of this by reading the famous book ‘Big Chicken’ written by health journalist, Maryn McKenna. However, the high use of farm antibiotics is also related to mass awareness, political commitment and strict regulations. While EU can continue livestock farming without prophylactic antibiotics for last 16 years, the countries in developing world cannot do it due to the abovementioned reasons.
Would you recommend any systemic changes to the way we raise livestock in order to preserve the efficacy of antibiotics?
To fight this global issue, the only systematic change required is to shift from intensive farming to organic farming. Though the solution is similar, the implementation must be different in LMICs and developed countries. First of all, the implementation phases and components need to be identified such as political and mass awareness, strict legislation and regulation, improving the farm biosecurity, antibiotic free supply chain from feed and day one chicken to retail consumers at market, ensuring the ‘withdrawal period’ before selling if antibiotics are used even for treatment purpose, insurance or financial policy for this industry, sufficient supply of required vaccines and professional training, sustainable OH-AMR surveillance in place etc. Many of these steps are already in place in the EU. However, despite many regulatory and programmatic measures, many EU countries such as Bulgaria, Cyprus, Greece, Malta, Poland, Portugal and Slovakia have seen increasing antibiotic sales in the animal sector to a greater extent than in previous years. Then, you can imagine what is happening in Asia, Africa and Latin America. My suggestion for resource poor settings is the concurrent focus on awareness, legislation and farm biosecurity at initial stages, then on financial policy and OH-AMR surveillance establishment. For developed countries, they should focus on environmental AMR surveillance and the engagement of more and more civil society organizations and professional bodies to be engaged in this process. For example, I have tried to show how the healthcare professionals in the EU can contribute in the antibiotic free food supply in hospitals by utilizing their purchase power.
Finally, the farming industry which has already banned animal growth promoters, such as in the EU, can start preserving a few antibiotics for future use. This will not work in LMICs where the environmental pressure of ABR is high. Bilateral diplomatic and business policy discussion with LMICs can be initiated gradually to ensure antibiotic free food imports and to align with global regulations.
How important do you think the environmental spread of antibiotic resistance is? Should farming industries take action to counter it?
In my earlier points and based on my engagement in AMR mitigation, I have clearly defined my focus which is the environmental dimension of antibiotic resistance. Whatever the measures taken to control the AMR issue, all will be in vain if the environmental selection pressure is not minimized. Particularly, the reason behind the failure to develop new antibiotics for decades largely lies in the abundance of environmental resistomes and their extraordinary ability to transfer the resistance mechanism in short duration. Undoubtedly, the animal farming and pharmaceutical industries are the two major contributors in the environmental dissemination of ARB. Minimal use of antibiotics and strict biosecurity with proper waste management should be in place for every animal farm and pharma production plant.
New EU legislation that came into force in the 28th of January 2022 bans routine farm antibiotic use and restricts prophylactic use to exceptional cases and for individual animals only. It also prohibits using antibiotics to compensate for inadequate husbandry and poor hygiene. The legislation limits metaphylaxis to cases when the risk of disease spread is high. Do you think these new rules are a step forward for responsible antibiotic use in farming?
This legislation will definitely help in ensuring responsible antibiotic use in EU farming practices. The EU has been working on this issue since January 2006 when they banned antibiotics as animal growth promoters. This regional initiative is definitely praiseworthy. Now, the strict implementation of the legislation needs to be ensured. However, the problem of AMR is global and travel, transport and trade can transmit it very easily to any place with strict regulation. In many EU countries including Scandinavia, the antibiotic use in humans and animals have been reduced but ABR trend is increasing.
Do you anticipate that these rules will deliver responsible farm antibiotic use or is further action likely to be required?
Along with such legislation and practice, more effort should be given to vaccine development for animal diseases and successful vaccination campaigns. In addition, a common food purchase/supply checklist in line with EU green public procurement could be practiced across Europe to ensure an antibiotic free food system from farm to fork.
Voluntary measures in the UK have seen farm antibiotic use fall by 50% over the last five years. What can the UK AMR community / farmers / farm vets / supermarkets and food retailers / contract caterers do to maintain progress?
The great success of reduced farm antibiotic use through voluntary measures in the UK is a clear indication of hard work. Case by case management instead of herd management by the farm vets along with responsible behaviour and a health focused approach by the farmers are definitely remarkable steps. To continue this success, sustainable and regular refreshers’ training schemes of vets (old and new), awareness meetings and workshops for farmers and continuous food safety screening for supermarkets/retailers could be effective measures.
The UK Government has chosen not to implement the new EU rules on farm antibiotic use and is instead still promoting a voluntary approach. What is your reaction to this?
AMR is ubiquitous but the drivers and control measures may differ based on settings and local capacity. Antibiotic residue is present in meat and dairy products in UK supermarkets which depicts the alarming trend of AMR. Not only that, UK is also one of the 10 top global consumers of antibiotics. The UK is not ready to implement strict regulation at this moment; one reason might be the recent success in farm antibiotic reduction via a voluntary approach. But I would definitely argue for mandatory implementation of the new EU rules in the UK. Before that, public-private efforts to enable mass conceptualization of the detrimental impact of AMR, improvement of farm biosecurity and hygiene and gradual insurance (& incentive) policies for the farm industry could be discussed and finalised with a trial period.
The UK is seeking and signing new trade deals with countries across the globe, what are the AMR risks and the opportunities of these new trade deals?
AMR is always a major concern in international trade agreements due to different production systems/standards in different parts of the world. The European Public Health Agency (EPHA) has already set a guideline on the public health risk assessment including ABR in bilateral trade and investment agreements. If the UK does not follow such strict guidelines, particularly for food (meat, dairy products, fresh produce/vegetables) and pharmaceutical product import, AMR will be an emerging threat in the UK and the whole of Europe as well. UK has also a moral (might be social/legal as well) responsibility to monitor the biosecurity practices of the source farms or industries so that they are not posing more risk of AMR in the host country for business deals.
The world has been shaken by the impact of covid, what can we do to prevent AMR becoming the next global pandemic? What advice would you give to world leaders about their response to AMR?
We can adopt several steps to prevent next AMR pandemic-
a. For LMICs-
b. For HICs-
The world leaders should consider ‘Public Health and AMR mitigation’ as one of their priority political agenda and no compromise should be made for individual, organizational, or economic benefit when the acts are executed in response to AMR containment.
What is the single most important thing to achieve if we are to win the fight against rising AMR?
‘No environmental dissemination of resistomes’.
-To take necessary measures for the prevention of environmental contamination with MDR bacteria, antibiotic residue and toxic chemicals/metals.
If you had $1bn to fight AMR, how would you spend it?
I would invest in capacity building for OH-AMR mitigation and surveillance but in three dimensions. First, I would initiate training and awareness campaigns on OH, PH and AMR for teachers and students in every school, for politicians and civil society organizations in every country and for religious, local community and indigenous leaders in resource poor settings. Secondly, for an effective industrial waste management system development (all sorts of industry-animal farm industry, pharma industry, chemical industry etc) to prevent their leakage into the environment. Finally, I would establish a uniform and integrated digital OH-AMR surveillance system globally with similar reporting and laboratory process.
Thank you for your time Dr. Muhammad Asaduzzaman and for giving us such a comprehensive insight into your work.
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