Animal and Environment Antimicrobial Resistance Delivery Group meeting: 22 March 2022

Becca Roberts (BR)
Joey Ellis-Iversen (JEI)
Sian Timms (ST)
Christianne Glossop (CG)
Ifan Lloyd (IL)
Geraint Hamer (GH)
Andrew Singer (AS)
Gavin Watkins (GW)
Catherine Cody (CC)
Sarah Guest (SH)
Rob Smith (RS)
Isobel Stanton (IS)
Kitty Healey (KH)
Chris Teale (CT)
Sarah Carr (SC)
Debbie Tynen (DT)

Ian Jones
Eifiona Williams
Wyn Evans
Eleri Davies
Robin Howe

A presentation was given by Joey Ellis-Iversen providing an overview of her review’s main findings and recommendations. Discussion followed afterwards.

AS: When the implementation plan was written in 2018 we were relatively blind in relation to Environmental data in Wales. Your conclusions in the review are accurate but we are definitely more clued up now. This item on erammp.wales gives a good picture

JEI: I think the environment factors are important, no doubt about that. But I believe they are more prevalent in developing countries where there are big pharmaceutical producers coupled with poor water treatment facilities.

AS: There is ample media interest on untreated sewage entering our water systems here in the UK. The things you emphasise in lesser developed countries are real problems here in the UK.

JEI: But isn’t this dependent on the number of AMs entering the water system?

AS: I think research in the last 6 years has challenged this theory.

CG: Interested in your challenge to us about where surveillance fits into our plan. It is an insightful comment that is really helpful. Can you expand on the point a bit more?

JEI: Surveillance tells us about the current situation. Ultimately, you are wanting to measure a drop in AMR and surveillance is how you determine this. Whether surveillance itself can be a goal, is questionable. I think it is more applicable in countries where there is currently very little surveillance already in place.

RS: I’m a farm animal practitioner in South East Wales. I’m curious how other countries are controlling AMU among vets. I agree that AM sales is a big driver in profits. Is there an article or resources to get information on other countries?

JEI: I have to say I’m most familiar with the Danish situation. There is a link with more information in the review that was circulated.  In Denmark there was a policy drive here to change the Vets role from being an AM dispenser to a herd health advisor.  In Denmark, how often farmers had heard health visits is determined by the amount of AMs they were able to administer themselves, to help incentivise. And there were also differentiated tax for AMs that were critical in human health.

Relevant links: : antibiotic use guidelines (ddd.dk); Antimicrobial guideline for pigs Denmark 2018 (foedevarestyrelsen.dk); SVS guidelines 2017.indd (svf.se)

JEI: Perhaps regulated veterinary medicines could be a point in the next plan?

GW: Veterinary medicines is not devolved and is the remint of the VMD. KH, care to comment?

KH: Our focus in the UK so far has been top down conversations to encourage change. The question is how far can we get with the voluntary approach and if top down measures are required.

IL: Welsh AMR data centre is a really interesting point. I believe there is a UK one being developed.

Presentation was given by Becca Roberts on the findings of the recent survey. Discussion followed afterwards.

BR: Would be interesting to know from the VMD how often they receive reports on AMs not working effectively.

KH: For suspected lack of efficacy, the VMD pharmacovigilance team receives very low numbers of reports. But generally we receive very few reports this way in any case.

SC: The presentation was really interesting. Not the results you’d expect either. I wonder if the equine practices who responded were mixed practices because they were already clued up on the subject. A lot of Equine practices are two man operations also operating in England and travelling across the border. Are you planning to give the results to the respondents? I think the vets would be really interested in seeing a one page summary perhaps.

GW: How would we do get the results to them Sarah?

SC: Most are signed up through BVA, so this would be a good line of contact. Practices that didn’t have a prescribing policy, you are supposed to have a policy for your VMD inspection. It’s definitely something that practices should have.

KH: It is a question on the inspection, yes. But it doesn’t directly link to the legislation however, so it’s there in the spirit of best practice. It is difficult to justify inspectors giving a heads up on that one specific inspection point prior to a visit.

KH: I wanted to raise your findings on surveillance. There seemed to be an appetite for it. Do you know what the respondents were looking for when they said they wanted more surveillance? Any personal insights? Just thinking a lot is already out there in the context of reports such as VARSS.

BR: We didn’t ask them that in the survey I’m afraid. Perhaps they are looking for more localised surveillance to increase awareness in practice, which feeds back culture sensitivities at a practice level?  Maybe Sarah would have more of an idea?

SC: One of the things I fed into the Arwain DGC webinar was that in-house culture sensitivity workshops are really cheap and cost effective to set up to get a cultural shift in practices.

BR: That would give you specific and tailored results rather than general information found in the VARSS report.

SC: It is important on a national level to know what bacteria and resistance strains are present. But from a practice perspective, the main thing you need to know is what ABs you actually need to be using rather than the specific strain of bacteria etc.

RS: In farm practice, we do want to know what the pathogen is but we want to leave that to the experts. Perhaps there should be a push towards Continuing Professional Development (CPD) and knowledge transfer to enable farm vets to do this themselves. There is a current attitude to leave it to the experts in farm practice but perhaps there’s an opportunity to get farm vets involved in this.

SC: Really good point RS made. In equine and small animal it is for individual treatments. Herd health is a totally different issue to tackle.

IL: Sometimes if you are doing AM sensitivity testing in practice, you need to have the right CPD there to ensure the right testing in the right situation. Vets need to be properly informed in these scenarios.

GW: On testing, there was clearly a demand in the survey for fast real time testing. Would love to discuss with our health colleagues about the state of rapid testing in human medicine. I’m not aware of anything in use.

CG: I visited a pharmacist a couple of years back that had capacity to test whether it was appropriate to administer AB for a sore throat or not. Any ideas around what this method was?

DT: Over the last couple of years things have slowed down or stopped in this area. I will have a chat with our pharmacy colleagues if it will be helpful?

CG It would, thank you.

DT: Will take that as an action.

IL: There are kits out there for farmers to use.

CT: I am aware that in human medicine they have protein testing for bacterial and viral infections. The problem is these proteins don’t act/react the same across species. We did have a test for haptoglobin for human medicine.

GW: We will take that away and do some research.

RS: There also is a Glutavac test which I use in bovines for fibrinogen levels which I use to decide if an animal needs antibiotics.

SC: Here in practice we take samples under the microscope for ear and throat infections.

GW: Would be great to have a follow up sessions with the practices that participated to get more information.  This survey was very much a baseline to understand the situation in the small animal practice. So that we can better understand what to do moving forward.

Action032: Group members will be aware that Gareth Thomas has now stood down. Not sure if we want to retain this action or if we want to close it?

GW: I think we should try to engage with YFC as they would be interested. Just take Gareth’s name off. If anyone would like to talk to the YFC then let us know.

GH RE Action 046: We’ve received a list of priority substances from VMD. Still quite long however. Need help from RH and ED to whittle the list down further. Perhaps worth a separate conversation, Gavin?

GW: Yes.

GW: Action 49, can be closed

ST: In emails that have gone out to the DG, we’ve asked for suggestions about replacement members. We will need to approach the FUW. Just need to have a discussion about who we invite.

GW: So if anyone has recommendations about farmer representatives that we could invite to the group, please do get in touch.

Environment Update

GH: AS and IS have been working hard on the topic of Combined Sewer Overflows. Safe to say we’ll have more of an update at the next meeting. Report is due April and will provide a further verbal update in June.

Health Update

DT: Not a massive update for you. From a human health perspective, hope we’re coming out of the mire a bit now with Covid. Allowed us to focus on other things again for the first time in a while. Hoping to regain a focus and put some effort into it.

Seen some strange prescribing practices that need unpacking lately. We need to go back to basics and reinstating some basic education and infection prevention control methods have gone backwards a bit as a result of Covid.

When we’re speaking with our UK colleagues, it is always our Animal and Environment colleagues that steal the show. Always very impressed and thank you for that. GW is coming to the UK delivery board meeting this Friday.

GW: That’s right, as well as KH. As animal health is the topic on the agenda.

GW: Wonder what effect remote AB prescribing has had. Would be very interested to learn what it has done to prescribing, perhaps PH might have a better insight.

SC: On what you were saying on remote prescribing. A lot of remote consultations go about the way of, shall we see what they’re like tomorrow. So probably prescribing less than in person consultation.

KH: Found a slide on what we have on companion animal prescribing in 2020, which shows that there was indeed a decline between 2019 - 2020. Will be interesting to see where that goes in 2021 and the following year. On farm animal side, it probably had very little impact, as they were key workers so very little changed in that respect.

VMD Update

KH: Raw Pet Food – currently funding a PhD on AMR on raw pet food. Very much a multi-agency thing. FSA and UK HSA interested in outbreaks in people. DARC raised the increased incursion as a result of an increase in imported meat. The PhD has shown the overall picture is numbers and quantity of resistance is reflected in the faeces of dogs that are fed this diet. So there is a quantitative risk.

SC: Scary but obvious those pathogens have been confirmed. What would be the mechanism by which labelling could be changed to warn people?

KH: A lot of what we hear from those who feed raw pet food is a polarised issue and people don’t want to listen. There is a growing recognition but who should lead on this is a harder thing to determine.

CT: For humans, root of infection can just be from handling the food and indeed the dog.

KH: One of the other, less directly linked consequences is there is the risk ending up in farm animal sector and the risks to the food chain.

GW: Is there a policy owner/lead between governmental departments?

KH: Not to my knowledge. This may have to change.

SC: KH mentioned the debate was quite polarising due to beliefs around benefits of raw feed. What I’ve found works quite well is to take the nutritional discussion out of it and to focus on the public health element. Keep it to a discussion about whether it’s safe to keep it in the house or not.

CT: FSA are having discussions on this. I’m inclined to think it is their remit. May be worth having a representative on this group?

GW: I often wonder if a 4^th leg of this group is AMR entering the food chain so it’s something I have considered from time to time.

CT: With raw pet food, one of the main risks is, if the meat is from outside Europe. The risk is reduced from inside the UK/EU. So the situation could be made better if the food was sourced from within the UK.

KH: Veterinary Medicines Regulations update - Not a lot has changed since last time. Consultation will take place later this year. No likelihood of lowering our ambitions on AMR. The kind of feedback we are looking for is if proposed changes are suitable. A paper has been released in EU on prophylactic use, clarifying what they mean by it. So it provides clearer definitions.

GW: Will the consultation accept responses from groups?

KH: No restrictions that I’m aware of. Will double check and feedback.

KH: National Action Plan has had a mid-point review and has been signed off.

GW: We fed into these discussions. There weren’t any major changes.

KH: No, nothing controversial. It was just a matter of making sure it still made sense in our current context.

KH: Agreed with FAO to assist them with a multi-stakeholder partnership platform. The purpose is to engage with people across the world.  Comes under the work of the AMR Reference Centre, but we are coordinating the work.

KH: As part of withdrawal period, it was agreed there would be dialogue around AMR. Had our first meeting to confirm our intent. Was a constructive meeting and it was agreed to focus on the international space.

KH: To flag a publication in the Lancet in January, the GRAM report, It updates the O’Neal estimates. It also has more comprehensive methodology. Also claims that Bacterial AMR is the 12^th leading cause in global deaths.

APHA

CT: Increasingly realising although animals are amplifying it, there is quite a lot of sewage going into the environment. Would this have been the case back in 2010 Andrew?

AS: It has gotten worse but it definitely would have been happening then.

CT: Still looking closely at this subject here at APHA. Environmental route is really essential if we want to ensure AMR is controlled. Especially among farm animals which have access to river water.

CT: Ban on zinc oxide. Often added to the diet of pigs to control illness. Proposed to be introduced in June. May cause issues in the sector when introduced. May lead to an increase in diarrhoea in pigs. A current area of concern.

GW: I remember suggestion there needs to be a change to management system of piglets to address this very issue. More of a husbandry issue than a pharmaceutical one.

CT: Later weening has been proposed as an option from Denmark, but this has an impact on productivity.

KH: Strongly suspect it’s relevant. In terms of later weening times, I remember discussions around this in 2015.

Cattle Antibiotic Guardian Group

IL: Waiting for the minutes to come back from the last meeting which I will share in due course to be circulated by secretariat. During the meeting we had a number of updates. On the VMR Consultation, there has been some feedback from RUMA. Had a good report from AHDB on AMU on cattle that they’ve collected. Also had an update on AHDBs medicine hub that’s due to be circulated soon.

Arwain DGC

RS: Things are starting to motor now. Menter a Busnes have launched their clinics.

12 proof of concept farms have joined the scheme and various projects are being rolled out such Cattle health monitors and IED in sheep.

University of Bristol – environmental sampling, 2000 samples across wales from farms. Received their training and packing materials. Due to kick off at the end of this month.

Iechyd Da – Getting farmers lined up to do the sampling.

Aber University – prescribing champions have enrolled another 6 new practices on the scheme. Up to 44 practices across Wales.

Working groups have been set up for Prescribing Guidelines and Code of Conduct for Wales.

Welsh Lamb and Beef Producers – continuing their work getting vet practices on the AMU calculator. They have increased the number of on-boarded practices by 35%.

Just sent out our monitoring and evaluation survey with partners input to decide where we are at this stage of the scheme. And another at the end to measure progress.

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Gavin: This is our main delivery project of our 5 year plan. At our next meeting in June we should have a deep dive on ADGC.

CG: What fantastic progress, this update has brightened my day.

SC: Back to the equine health clinics, we’ve had a webinar for horse owners and vets that were both well received. The health clinics, are sponsored by Arwain DGC to pay for the vet’s time. So anyone with links to equine practices, please share the Arwain DGC’s media comms to encourage uptake.

RS: There may be a comms issue with this. When Farming Connect vouchers were out, farm vets snapped right up. Do you think we just aren’t getting out to the horse vets? What can we do here to encourage take up? Maybe through BVA?

SC: BVA is a good idea. Plus specific facebook groups. But they are an elusive bunch. A lot of horses are served by mixed practices. And only 3 or 4 big practices and the rest are two man bands servicing a large portion of horses in Wales.

Due to time constraints it was not possible to cover this agenda item.

Arwain DGC event at the Royal Welsh

• As briefly mentioned in the meeting, Arwain DGC are hosting an event at the Royal Welsh Show. The event is due to take place on Wednesday 20 July. Further information will be shared with group members as it becomes available.

Delivery group vacancy

• We’re still inviting recommendations from Group Members for candidates to fill the recent vacancies. Please feel free to reply with any suggestions you have.

Future steps delivery group survey results

• Due to time constraints we were unable to cover this agenda topic. This will now form part of our agenda in June, when we will also be considering how to implement the recommendations made in Joey’s report.

Next Meeting Date

• Our next quarterly meeting is due to take place on 21 June 2022.