Summary of RUMA/VMD Conference on Responsible Use: Ideas into action
Around 170 delegates and speakers attended the conference, held at Sainsbury’s auditorium in Holborn, London. This One Health conference considered the serious risks to human and animal health caused by antibiotic resistance and the importance, therefore, of using medicines responsibly. Speakers from the livestock, human health, media and education sectors spoke on:
- What do we mean by Responsible Use?
- What influences Responsible Use?
- Measuring and Monitoring Medicine use
- How do we communicate what we are doing?
A number of key points were made by the speakers and delegates in the discussion sessions built into the agenda. These included:
- Acknowledgement that AMR is a very complex issue and it was important for all sectors to work together, with respect for each other, to reduce the development of resistance and maintain the efficacy of existing antimicrobials. The key driver for all this work was to reduce the AMR risk in human medicine.
- There was a call for a clear definition of Responsible Use. RUMA’s definition, which is in all RUMA Guidelines, is for farms to be managed so that the risk of disease challenge and therefore the need to use a medicine is reduced. Animals should be treated properly when they become ill i.e. in accordance with vet diagnosis and label/vet instructions re medicine use. So medicines should be used “as little as possible and as much as necessary”.
- One comment from the floor asked what is our endpoint – what does success look like and how will we know when we get there? This is an excellent question and one that we all need to consider. For veterinary use it could be being able to justify every use of antimicrobial in an animal in terms of both animal welfare and human health.
- It was acknowledged that doctors face a dilemma of individual patient well-being versus the greater good when deciding to use an antibiotic. There can be risks of an infection developing and diagnosis is not black and white. There was a clear need for better diagnostic tools in both human and veterinary medicine.
- Research had indicated that doctors and vets need to speak to patients/animal keepers about antibiotic expectations and not make assumptions that an antibiotic prescription was expected.
- Should farmers be allowed to continue to treat animals without any qualifications? Should they be licensed to farm?
- It was clear from the speakers that there is a great deal of work on antimicrobial stewardship being carried out across livestock sectors and more is planned. This was welcome but this work must not be done in silos and the livestock sectors must learn from each other and the work being done in human medicine.
- Developing a business case and peer pressure were recognised as key drivers for change. It was recognised that the work on antibiotic usage data collection will enable farmers and their vets to consider and review the outcomes of their antibiotic use and its impact on productivity. Farmers and vets must work together to use these data to make decisions on future antimicrobial use.
- A number of speakers raised the need for clear communication and there was concern that RUMA’s work with the media was poor and needed an overhaul. In particular, RUMA needs to be more open in admitting that issues exist and explaining how we plan to address them. One of the summarisers said you need courage to communicate properly!
- A number of people said strong leadership is required and one asked who is leading? This might be considered disappointing for RUMA, who have tried to adopt a lead role in collaborating the livestock sector’s work on AMR. This has been highlighted by RUMA’s 5 Year AMR Strategy Action Plan which is driving and recording the livestock sector’s work to implement the Strategy. But in order to continue this lead other parties aligned to RUMA perhaps need to work more closely together for the common good so the positive messages about Responsible Use are synergistically magnified.
The presentations made by each of the speakers can be downloaded. The following is a synopsis of their talks plus points of note made during the presentations or discussions.
Professor Dame Sally Davies, FRS, FMedSci, Chief Medical Officer
Dame Sally opened the day by talking about the history of antibiotic use, and how this has led to the situation today where the bugs are once again ‘winning the war’. She touched on antibiotic use in the animal sector and the impact that this has on human health.
Dame Sally said it was important for us all to work together with respect. She acknowledged the work done in aquaculture in the UK and Norway to reduce antimicrobial use but said that antibiotic consumption in livestock is increasing around the world. Use of antibiotic growth promoters had been banned in the EU but how can we stop their use the in rest of world?
Session 1 What do we mean by Responsible Use?
Meryl Ward, Chair AHDB-Pork
Meryl said that Responsible Use of Medicines is a key priority in the pig industry strategy to deliver safe and traceable pork. Responsible use starts with an active veterinary health plan based on preventive medicine and supported by targeted surveillance. She outlined the plans for a new electronic hub for benchmarking antibiotic use which will encourage action and revision of veterinary health plans. Many factors combine to improve health and welfare and reduce antibiotic usage of which environment and training are identified as critical for the pig industry. A responsible approach to voluntary regulation with robust policies, cross-industry commitment, a staged process and an open mind to advances in technology are already making significant inroads into health and welfare and reduction in antibiotic use.
Meryl said that the pig industry had to justify its high welfare credentials. The vet is the most important part of a team approach to develop a holistic approach to responsible use. On her own farm, Meryl said that her vet has become a key part of the management team with fortnightly visits for advice and he is paid as a consultant. This helps her to comply with Red Tractor standards which require quarterly vet visits to members’ farms i.e. for 95% of pig farms.
An important element of responsible use of medicines was an active veterinary health plan which farmers and vets should use to benchmark results, identify actions and adapt to keep it relevant.
Meryl did not believe that legislation should be needed to force reductions in antibiotic usage. Farmers and vets should be able to achieve this by working together using, for example, improved diagnostics, good biosecurity and post mortem and other data. On-farm training was required to provide the how and why for medicine use. Such training would be enhanced through better benchmarking tools to help famers compare to their peers and learn from each other. Training is the key for better knowledge transfer.
Meryl said the farm environment was also important. Pig housing improvements go a long way to help reduce disease risk but there are few manufacturers of pig housing and farmers need profit to invest. It would also help if farmers could offset the cost against tax.
Dan Parker MRCVS, Veterinary Adviser, British Poultry Council
Dan outlined the development of the British Poultry Council (BPC) antibiotic stewardship group to develop and support the sector in responsible use of antibiotics in the meat sector. The group championed education of the sector as well as pioneering the collection of antibiotic usage data to allow members to benchmark their progress in responsible use. He said the stewardship programme included non-BPC members and individual companies had adopted their own stewardship policies. Further work is ongoing on replace, reduce and refine strategies within member companies:
- Replace antibiotic use e.g. vaccines
- Reduce antibiotic use
- Refine – e.g. use external experts to review colistin use after it became critically important in humans.
The BPC was also co-operating with and funding research into critical areas such as ESBL and LA-MRSA.
The BPC had been collecting antibiotic usage figures for a number of years and shared these figures with the VMD for use in their annual reports 2015. The bottom quartile of farms i.e. those with the highest antibiotic use, are given an action plan from their vet to help them reduce their use.
Dan said the BPC support continued access to antibiotics used responsibly to protect health and welfare but did not support a ‘race to the bottom’ i.e. no antibiotic use in animals, which is unrealistic.
Peter Edmondson MRCVS
Peter highlighted the changes in how medicines are currently used in dairy herds as they increase in size, the changing role of the dairy vet, current veterinary involvement in treatments, farmer challenges as they are the people who administer the majority of antibiotics and how this all fits in with responsible use of medicines.
He said that dairy farming involved individual animal treatment and the trend is for bigger herds, less farms and more foreign workers. Vets prescribe and supply but, like doctors, do not know how medicine is used. Peter commented that there are no training requirement to administer veterinary medicines which led to a discussion about training and qualifications for farmers to make them more professional. It was suggested that there was a need for vets to run training courses for farmers.
Peter said that vets are seeing fewer sick animals because farmers are better educated so there is less disease but also because farmers are concerned about vet costs and so use the vet as an emergency service only calling one out if there is a problem. Most antibiotics are given by dairy farmers are in udder treatments and there was a move to selective Dry Cow Therapy which could lead to a reduction in antibiotic use. Peter mentioned a paper by David Tissall of Bristol Vet School on using no 3rd and 4th generation cephalosporins in dairy cattle.
In summary, Peter said there had been a significant increase in disease prevention and uptake in vaccine use but there were opportunities to reduce disease further. There were new initiatives to reduce antibiotic use and farmers and vets are aware of responsible use.
Professor Chris Butler, FRCGP
Chris Butler presented the development of theory-based behaviour change interventions aimed at enhancing the quality of antibiotic prescribing in general medical practice and described their evaluation in randomised trials. He said that 80% of human use of antibiotics in England was in Primary care and it was though that between 50 and80% of these antibiotics could be misuse. But microbiologists mustn’t take an over simplistic view. For doctors prescribing their priority is patient well being and not necessarily the general good. Research had indicated that many patients now expect not to have antibiotics.
So there needed to be a One Health acceptance of the need to change antibiotic use which recognised that change was both important and feasible. Prof Butler mentioned examples of the actions taken in primary care to reduce antibiotic use and which could transfer to the veterinary sector. These were:
- better communications and better point of care testing which had led to up to a 75% reduction in antibiotic use
- an interactive booklet for parents to help look after their children had led to a 20% reduction in antibiotic use
- a Target Antibiotics toolkit on the Royal College of GPs website.
RUMA will consider how these examples could be applied to the veterinary sector.
Dr Fiona Lovatt, MRCVS
Dr Lovatt said that due to its extensive nature, the sheep industry has a reputation as one which uses minimal quantities of antimicrobials. However, there is no room for complacency and she considered the key areas of lamb production where ‘responsible use’ is important. In particular, she considered the development of anthelmintic resistance which has a high profile within the sheep industry and how this issue has been tackled by SCOPS a pan-industry initiative over the past 10 years.
Dr Lovatt said the small antibiotic use in sheep was mainly in routine treatment for neo-natal lambs, enzootic abortion or foot rot. She thought the short version of the RUMA Guideline on antimicrobials in sheep production was excellent but the long version needed updating and RUMA will consider this.
Dr Lovatt was concerned by the lack of vet involvement on sheep farms and their veterinary health plans. Unfortunately, farmers did not consider the sheep vet as a key part of sheep production. Most medicines are supplied by SQPs.
Anthelmintic resistance is a bigger problem than antibiotic resistance for sheep production. Recent research by HCC in Wales shows increasing numbers of farms with multiple resistance. This highlighted the importance the Sustainable Control of Parasites in Sheep (SCOPS) group. SCOPS was a model example of industry self help involving all groups involved in sheep production to develop guidelines to help farmers reduce the risk of anthelmintic resistance by using them responsibly.
Dr John Webster, Technical Director, Scottish Salmon Producers
Dr Webster set the scene saying that, globally, fish produced for human consumption through aquaculture now exceeds the total wild catch. With both the human population and per capita consumption of fish increasing it is inevitable that aquaculture production will continue to grow as wild stocks decline and further management measures are introduced.
He said that there was very little antimicrobial use in aquaculture in the UK with only 1 tonne of antimicrobial active ingredient used for annual production of 179,000 tonnes of fish. Sea lice are the biggest problem and the industry was moving to non-medicinal interactions such as using wrasse and other small fish to eat the lice.
Dr Webster said that the industry had developed a Code of Good Practice for Scottish Fin Fish Aquaculture which draws heavily on RUMA Guidelines.
Session 2 Panel discussion on What influences Responsible Use?
Chaired by Professor Pete Boriello, CEO, VMD a panel considered what influences responsible use and discussed comments from delegates. The panel included
- Professor Chris Conlon, MA, MD,FRCP, Consultant Physician Infectious Diseases, Oxford
- John Blackwell, MRCVS, Senior Vice-President BVA
- Professor David Barrett, MRCVS Bristol Vet School
- Gwyn Jones, RUMA Chairman
- Dr Ian Brown, OBE, BSc(Agric), FRCP, FFOM, Consultant Physician, University of Oxford, Chairman of the Advisory Committee on Animal Feedingstuffs and member of the RUMA Alliance
- Dr Tim Chadborn Public Health England, Behavioural Insights Team
The panel were in agreement that that education and behaviour were key drivers for influencing responsible use. In particular, there was a need for training to bring about sustainable behaviour change. A clear aim was needed along with strong leadership. Peer pressure was also important as it was a good way to spread best practice. The Role of retailers in influencing responsible use in agriculture was recognised, including the possibility of influencing non-EU suppliers which would help the global aspects of AMR. One of the retailer representatives said she would try to get a meeting arranged via BRC to explore this further. The need to remove antibiotic growth promoters from non-EU production was emphasised.
Session 3 If we can’t measure it we can’t control it
Liz Redmond MRCVS, VMD
Liz Redmond started the session by giving an outline of the strategic context and drivers for the collection of data on antibiotic usage in animals from a public policy perspective. The need for a better understanding of what and how antibiotics are being used in animals is highlighted by the UK’s 5 year AMR strategy and in European regulatory proposals and activities. The VMD already has good data sets on the quantity of antibiotics sold by veterinary pharmaceutical companies but information is lacking on the level of usage in each species of animal. The VMD recognised the key facilitating role of government in this area and Liz set out her work leading a programme to develop a co-ordinated UK national approach to data collection by species since early 2014. Priority has been placed on key livestock sectors i.e. pigs, poultry and cattle, and in each sector innovative and collaborative approaches have evolved and are growing to provide, over time, data suitable for national collation in a new VMD central data hub. This work is ongoing but illustrates the power of the UK animal sectors to identify and solve problems in a collective and creative way.
Martin Smith, MRCVS, AHDB Pork and Pig Health and Welfare Council Antimicrobial Use Sub-group
Martin Smith outlined the strategic approach being taken by the Pig Health and Welfare Council (PHWC) Antimicrobial Use Sub-group. The subgroup has recognised that the existing data on antibiotic usage within the pig sector is not reliable and does not reflect the true levels of usage on farm. The PHWC sub-group, in conjunction with AHDB Pork and the Veterinary Medicines Directorate, has developed the specification for a database to record on farm medicines usage. The system is currently being built with a launch date of April 2016. It will have the capacity to be used as an electronic version of a medicines book and will also meet quality assurance scheme requirements (Red Tractor and QMS assured). Whilst the remit of the PHWC Antimicrobial Use Sub-group is wider than just developing a system to measure antibiotic usage, it has been widely accepted that without reliable data on levels of antimicrobials used, it is difficult to develop a targeted strategy for good antibiotic stewardship.
Máire Burnett, Technical Manager, British Poultry Council and Poultry Health and Welfare Group
Máire gave details of how the British Poultry Council collects antibiotic usage data from the poultry meat sector and how this data is presented to the VMD. She also provided an update on where the other poultry sectors are with their plans for collecting antibiotic usage data.
Brian Lindsay Secretary, Cattle Health and Welfare Group
Brian said that the AMR issue is fuelling many initiatives related to antimicrobial use in both humans and animals and the EU is currently working on developing systems to appreciate the levels of antimicrobial use in member states. Having reviewed recording systems throughout the EU, the VMD recognised that many of these were not transferable to the UK cattle sector and as such there was a need to better understand our current situation and importantly, get ahead of the curve in establishing recording and reporting systems that we in the UK are comfortable with as opposed to having a potentially unsuitable system imposed on us.
As a result the Cattle Health and Welfare Group were commissioned by the VMD to get an appreciation of the potential to export anonymised and aggregated medicine use data from cattle, both beef and dairy, farms. This involved a two pronged approach, starting with a series of interviews with a range of cattle farmers and support industries. At the same time the British Cattle Veterinary Association surveyed their members to ascertain if there was a potential to extract antibiotic use data from veterinary practice software.
The outcomes confirmed the CHAWG’s belief that although records were maintained on farm for legal compliance and farm assurance purposes, there was very limited export of this information away from the farm for any further use.
Brian said the cattle sector has opportunity to establish a system of data collection, from predominantly paper based records, in an unbureaucratic process that will also return value to the farmer. A cattle sector workshop will be held in early 2016 to explore the issue with the aim of collaboratively designing a system, which could very well align with the excellent system designed by the pig sector, in an effort to achieve our aspirations.
Dawn Howard CEO, NOAH – Compendium App
Dawn explained that NOAH (National Office of Animal Health) represents the UK animal medicines industry, with over 90% of the UK animal health market. Promoting the benefits of safe, effective, quality medicines for the health and welfare of all animals, NOAH supports the responsible manufacture, promotion, sale, distribution and use of animal medicines.
For many years the NOAH Compendium has been an essential reference tool for medicines prescribers such as veterinarians and SQPs (Suitably Qualified Persons). Updated annually, it is available in hard copy and supplied to all veterinary practices plus many universities and colleges as the key source of information on veterinary products to aid responsible prescribing and use.
Dawn said that the NOAH Compendium is also available online at www.noahcompendium.co.uk and regularly receives over 2,500 views per day. NOAH is now bringing the Compendium up to date with new software, making vital information available in real time and via mobile apps (iOS and Android), enabling users to access Compendium data remotely. Data will now be linkable to wider industry partners both for recording medicines usage, in particular antibiotics, and to aid responsible use. Other features will be added to help users access Compendium information and record medicines as accurately and easily as possible, keeping the NOAH Compendium as the key reference for veterinary medicines.
Phil Sketchley, BSc (Hons), Hon Assoc RCVS – NADIS Farm Medicines Tracker
Phil explained that when the new European Veterinary Medicines regulations to come into force, possibly in late 2017/2018, it is clear there will be a requirement for vets and farmers to record a high level of detail of antibiotics prescribed and used in farm livestock.
He said it is important that new tools and systems are made available to the farmer to help them comply with these additional requirements. The Farm Medicine Tracker has been set up in partnership with NADIS (www.nadis.co.uk). It will enable the farmer and their vet to electronically record medicine usage more easily, automate the process of logging that information for feeding into the regulatory hub recording, and also provide additional tools to aid and improve the management of animal treatments by the farmer and their vet, thereby providing a practical ally in the Responsible Use of medicines and enhance the measurable outcomes of treatment.
Session 4 How do we communicate what we are doing?
Professor Guy Poppy BSc, DPhil, Chief Scientific Adviser to the FSA
Professor Poppy said the Food Standards Agency is a Non Ministerial Government Department created by an Act of Parliament (1999) established to “protect public health and interest of consumers in relation to food”. A new strategic plan has been agreed for 2015-2020 focussed on “food we can trust”. Central to this is ensuring consumers are protected from unacceptable risk, can make informed decisions and have the best food future possible. The issue of AMR and how the food system contributes to AMR is an important issue and we have just initiated a systematic review to establish the evidence base and gaps. On AMR the FSA work with its Advisory Committee on the Microbiological Safety of Food (ACSMF) and other partners. The ACSMF set up an AMR Working Group in 2013 which is about to report.
He said the FSA put consumers first in their risk assessment, risk management and risk communication roles. They are carrying out a LA-MRSA risk assessment which is due to be published in Spring 2016.
Prof Poppy reminded delegates that consumers can protect themselves from bacterial infection from food by following the 4Cs advice on the FSA website i.e.
- Proper Cooking
- Proper Cleaning
- Proper Chilling
- Avoiding Cross-contamination
Amy Jackson Oxtale Specialist Communications
Amy said there was much more to be done to get over the information on what the livestock sector is doing about the issue of antibiotic resistance on-farm. She said that if she had less information than she did now, she would be horrified by a search on Google or Twitter. It’s an A-list of environmental lobbyists, pressure groups and anti-farming (or anti-efficient farming at least) campaigners hogging the top of the search engine results. Anyone forming their views from this would have a very polarised opinion. So we have an issue. But there are people out there managing issues very well and from whom we can learn. Examples included the government/industry collaboration that is reducing farm antibiotic use in the Netherlands, the information and discussion in the US via US Farmers and Ranchers, and the Food Dialogues initiative.
Amy said there is much to learn from these approaches. But first we have to accept we have an issue here in this country that we aren’t dealing with. The industry needs to work together to address it – at the moment there’s too much fragmented activity. We also need to adjust our tone and message. Currently, the industry information I read looks at best defensive, at worst, evasive. Let’s get real: there’s an issue, it’s affecting us, human use is the main problem, not animal, but we have a clear contribution to make. We need to be doing more – act, engage and secure our share of voice. We can’t communicate in a void; let’s also make sure there’s activity behind it. And remember – we can’t influence the message if we aren’t in the debate.
Tom Sheldon Science Media Centre
Tom explained that the Science Media Centre is focused on the controversial science stories that hit the headlines. They see crisis and media rows on issues like badgers, antibiotic resistance, bees and pesticides, swine flu and foot and mouth as an opportunity as well as a threat. By avoiding controversy scientists lose out on the opportunity to engage the public and policy makers with the very best science and information available.
Tom used case studies to make the case for more scientists to enter the media fray when their issues are being misrepresented by journalists or campaign groups and explain why the SMC’s philosophy states: ‘the media will ‘DO’ science better when scientists ‘DO’ the media better’. He said that the SMC use scientific experts to provide comments for journalists and encouraged more experts from the livestock sector to get on their books.
Tony Davies City & Guilds Responsible Use Qualifications for Veterinary Medicines
Tony explained that City & Guilds offer a range of Certificates of Competence in various disciplines which are widely used in the land based industries. There are various livestock qualifications which are used in both agriculture and animal care. With the previous comments on the need for education and better trained farmers, Tony set out the opportunity for a stock person to take a relevant qualification – City & Guilds Level 2 Certificate of Technical Competence in the safe and responsible use of veterinary medicines. He explained how candidates could access the necessary training and assessment for the qualification which will be launched in February 2016. Tony gave a brief summary of the content of C&G’s qualification on the safe and responsible use of medicines on farm which provided an opportunity for all administering medicines to animals. RUMA will be using this work to develop the RUMA training toolkit on responsible use.
John FitzGerald Elizabeth Marier