>> Recorded.
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on your phone to ask a question.
I would now like to turn the conference over to Laura Murell.
Thank you.
And, you may begin.
>> Thank you Tasha.
Good afternoon everyone.
My name is Laura Murell and I work in the One Health Office
of the National Center for Emerging
and Zoonotic Infectious Diseases at the Centers
for Disease Control and Prevention.
On behalf of the One Health Office,
I'm pleased to welcome you to the monthly Zoonoses
and One Health Updates Call on November 6th 2019.
ZOHU Call content is directed to epidemiologists, laboratorians,
scientists, physicians, nurses, veterinarians,
animal health officials,
and other public health professionals at the federal,
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or commercial supporters.
Before we begin today's presentation,
Dr. Casey Barton Behravesh,
Director of CDC's One Health Office,
will share some news and updates.
>> Hi everyone.
Thanks for joining us for today's ZOHU Call and welcome
to all of our new participants.
The ZOHU call audience continues to grow
with subscribers representing professionals from government,
nongovernmental organizations, industry,
and academia including students.
We appreciate your help
to continue spreading the word about the ZOHU Call.
Please continue to share the ZOHU Call website link
with your colleagues from human, animal, environment,
and other relevant One Health sectors.
The site includes links to past call recordings,
information on free continuing education for a variety
of professionals, and a link to subscribe
to the ZOHU Call email list.
To begin today's call, I'd like to share a few highlights
from the One Health News from CDC which were included
with today's ZOHU Call Newsletter.
First, CDC has launched Life is Better with Clean Hands,
a new national handwashing campaign.
And, CDC's Climate and Health Program is celebrating 10 years.
There's some recent and upcoming observances and events.
I hope everyone enjoyed One Health Day on November 3rd.
It was great to see all the promotions
and the information being shared on social media.
We have Antibiotic Awareness week, November 18th to 24th.
And, all three of today's presentations are
about antibiotics.
The World One Health Congress will be
in Edinburgh Scotland June 14th through 18th.
The call for abstracts is now open and applications
for the One Health Fellowship Fund
to attend the conference are due on January 15th.
We've shared links to recent publications
on several topics including incubation periods
of enteric illnesses in Foodborne outbreaks in the U.S.
And Fatal Lyme Carditis in New England.
Regarding outbreaks, there are two new outbreaks
of Salmonella infections that have been posted.
And, final updates have been posted for three outbreaks
of salmonella infections linked to contact
with Pig Ear Dog Treats,
Backyard Poultry, and Pet Hedgehogs.
A list of selected and ongoing and past U.S. outbreaks
of zoonoses as well as information on staying safe
and healthier around animals is always available
on CDC's Healthy Pets Healthy People website.
The complete CDC Current Outbreak List,
including foodborne outbreaks and others,
is available at cdc.gov/outbreaks.
As always, if you would like for us to share news
from your organization or if you want
to suggest presentation topics or volunteer to present
on a future ZOHU call, please contact us at zohucall@cdc.gov.
Again, thanks for supporting the ZOHU Call
and for joining us today.
I'll now turn the call back over to Laura.
>> Thank you.
Today's presentation will address one or more
of the following objectives.
Describe 2 key points from each presentation.
Describe how a multisectoral One Health approach can be applied
to the presentation topics.
Identify an implication for animal and human health.
Identify a One Health approach strategy for prevention,
detection, or response to public health threats.
Identify 2 new resources from CDC partners.
Questions for all presenters will be taken
at the end of the call.
Call 1-800-593-8936 and enter participant pass code 9611836.
Press star 1 and give the operator your name
and affiliation.
Please name the presenter or topic
at the beginning of each question.
You'll find resources and links for all presentations
on our website and in today's ZOHU Call email.
Our first presentation, One Health
and Antimicrobial Resistance, a United States Perspective,
will be given by Dr. Susan Bright-Ponte.
Please begin when you're ready.
>> Good afternoon.
My name is Dr. Susan Bright-Ponte
and I'm a veterinarian at FDA Center
for Veterinarian Medicine or CVM.
And, I currently work within CVM's Office Surveillance
and Compliance on a variety of issues related
to antimicrobial use and antimicrobial stewardship
and veterinary studies.
I do want to take the opportunity
to thank the ZOHU planners for inviting me
to present on this topic.
And, basically, this presentation is a brief summary,
excuse me, summary of a collaborative article
which was authored by representatives
of several different U.S. Government agencies.
So we had FDA CVM representatives,
as well as the USDA Animal and Plant Health Inspection Service
or APHIS, the USDA Agricultural Research Service or ARS,
the CDC, and the, also the Minnesota Department
of Health all participated in putting this article together.
This article was published earlier this year.
And, it was part of a special One Health issue
of the World Organization for Animal Health or OIE,
their Scientific and Technical Review.
And, the issue was entitled Successes
and Remaining Challenges Within the One Health Approach.
So this article is really an excellent opportunity
for our agencies to really successfully collaborate
and share information about our efforts in the area
of antimicrobial use and resistance
across the One Health spectrum.
And, the title of the article, as you can see, is One Health
and Antimicrobial resistance, a United States Perspective.
So on today's talk,
I'll basically just give a very brief background
on antimicrobial resistance or AMR,
why it's a One Health issue.
I'd like to give an example
of a One Health collaborative approach,
which is the National Antimicrobial Resistance
Monitoring System or NARMS.
And, give some additional examples, also of efforts
of human healthcare, animal healthcare,
and environmental sectors in addressing the problem of AMR.
And, also, we'll just point out, at the end, a few data gaps
and potential research needs as well.
So for a little background,
antimicrobial are basically just drugs that kill
or inhibit the growth of microorganisms
which could be bacteria, viruses, fungi,
parasites, or protozoa.
But, for the article and for this presentation,
we focus on antimicrobial resistance specifically
in bacteria.
And, bacteria can be resistant to an antimicrobial
when they can survive and reproduce even in its presence.
So there are textbooks written on this subject.
So I'm very briefly just going to touch on a couple
of other basic things in terms of types of AMR.
Essentially, there are two main types;
naturally occurring, and acquired.
So naturally occurring is also sometimes called intrinsic
resistance, which means, you know, because of the mode
of action of a particular antimicrobial drug,
it may just simply not be effective
against a certain bacteria.
Whereas, acquired resistance means
that the bacteria was initially sensitive to an antimicrobial,
but then they acquired the ability to resist the effects
of that antimicrobial, through various mechanisms.
And, some examples of potential mechanisms could just be
that there could have been spontaneous mutations
that result in prevention of an antimicrobial drug
from being able to bind
to its usual target on a bacterial cell.
Or there could be other mechanisms like acquisition
of enzymes that inactivate the antimicrobial
or even efflux pumps that actually will pump
out the antimicrobial from the bacterial cell.
So those are just a few examples of some mechanisms
through which bacteria could potentially acquire resistance
to antimicrobials.
And, then we talk about the drivers of AMR.
And, I've listed two of the main ones here;
Antimicrobial selection pressure and then Transmission.
So antimicrobials can cause a selective pressure
by essentially killing the susceptible bacteria
which then allows or selects for antimicrobial resistant bacteria
to allow them to be able to survive and multiply.
Well, sometimes co-selection is also a factor where resistance
to multiple classes of antimicrobials occurs.
And, that could be because of shared resistance mechanisms,
in the case of cross resistance,
or there could be genetic linkages among resistance genes
in the case of total resistance.
So in those ways there can be resistance
to multiple classes of drugs.
And, then in terms of transmission,
which is another main driver of AMR, what I'm referring
to here is just the spread of resistant bacteria
which could be transmitted between patients
and healthcare workers or between people and animals
or between environments.
So that antimicrobial exposure
in a single instance actually could pose risks,
locally as well as ultimately to the global community
through travel and stuff like that.
So resistant organisms may spread though be it direct
or indirect contact or through environmental surfaces
or waterways and also could be transmitted
through the food chain.
So the impacts of AMR are pretty substantial.
In the U.S. an estimated 23,000 people die each year due
to antimicrobial drug resistant infections.
And, that could also add as much as $20 billion
in direct healthcare costs annually and $35 billion dollars
in lost productivity costs annually.
And, resistant infections often lead to, you know,
treatment with last resort antimicrobials
and could also result in longer periods of hospitalization
because they're more complicated obviously.
Resistant infections also effect animal health with a loss
of effective disease treatment options
and potentially increases in morbidity and mortality.
So before I discuss how AMR is a One Health issue, I just wanted
to remind everyone of the definition of One Health.
Which is the collaborative effort of multiple discipline
and sectors working locally, nationally, and globally
with the goal of achieving optimal health outcomes,
recognizing the interconnection between people, animals, plants,
and our shared environment.
So any use of antimicrobials, whether it's in humans, animals,
crops, or other areas in the environment, have the potential
to contribute to antimicrobial resistance issues.
Antimicrobials are used in human healthcare
such as acute care hospitals, long term care facilities,
outpatients facilities.
Also in animal or veterinary medicine,
antimicrobials are used in the similar types of settings
as well as in all types of species.
So you're containing animals,
food producing animals, aquaculture.
And, antimicrobials are also used in crop
and fruit tree production sometimes.
But, in all of these sectors, antimicrobials could be needed
for use in the treatment or prevention or control
of bacterial diseases.
So all of these sectors also have a role in the transmission
and spread of antimicrobial resistance.
And resistant bacteria can actually be transmitted
between species, like I said, and between ecosystems as well.
And, that basically demonstrates
that AMR needs a One Health approach
in terms of addressing it.
This figure is from the article, the published article.
And, basically demonstrates some of the interconnecting paths
of the different ecosystems and potential routes of transmission
of antimicrobial resistant bacteria between the systems.
For example, just one example would be the manufacture
of antimicrobials in an industrial system could result
in discharge of antimicrobials
into water systems ultimately spreading potentially exposing
animals, humans, and other parts of the environment
through these potentially multiple pathways.
So with all of this interconnectedness,
it's clear again that the,
confronting AMR does require this type
of multidisciplinary approach at local,
national, and global levels.
And, it does, kind of, require us
to acknowledge the shared responsibilities
across the sectors.
It requires ongoing and enhance surveillance and monitoring
of antimicrobial use and resistance across all sectors.
It also is important
to implement good antimicrobial stewardship practices
in all settings.
And, to promote the development of alternatives
to antimicrobials which could include infection control
practices that would ultimately, hopefully,
help reduce the incident of infections
and thus reduce the use of antimicrobials except
when they're needed, obviously, for therapeutic purposes.
So while antimicrobials will always be needed as a tool
to fight bacterial diseases, there are ways that we can work
on trying to optimize their use
and ultimately preserve their effectiveness.
In 2015, the U.S. Government released the National Action
Plan for Combating Antibiotic Resistant Bacteria or CARB.
There are 5 main goals to the plan.
And, actually, just to let you know, there is work
on updating the plan for the next 5 years.
But, one of the main, one of the main 5 goals
of the current plan, as I've bolded here,
is to strengthen national One Health surveillance efforts
to combat resistance.
So this is kind of one
of the collaborations this article is one collaboration
just to kind of summarize some of the activities.
But, there are many collaborations going
on across multiple sectors addressing this issue.
And, one that I did want to go into a little bit of detail
about is the NARMS program.
NARMS is the National Antimicrobial Resistance
Monitoring System.
And, this was a program, partnership established in 1996.
And, it was, it started out as a partnership
between FDA, CDC, and USDA.
And, these are still the three partners involved.
And, basically, also within the program though are 54,
about 54 I believe state, territorial,
and local public health departments all working together
in this partnership.
So this program, it's a surveillance program
which tracks antimicrobial susceptibility among intestinal
bacteria isolated from ill humans, retail meats,
and animals at slaughter.
And, I've listed here the current objectives of NARM.
You know, basically again, to monitor the trends
in AMR among specific foodborne bacteria, which I'll talk
about here in a minute.
To disseminate timely information, conduct research.
And, also one of their objectives is to assist the FDA
in making decisions related to the approval
of antimicrobial drugs for animals.
So this is a slide which basically just shows a summary
of what each, what we call ARM of NARM Monitors.
So on the left the USDA,
basically the Food Safety Inspection Service monitors food
animal samples or chicken, turkey, cattle,
and swine through a fecal sampling program.
Sampling takes place near the time of slaughter.
And, then in the middle panel we have,
we show the FDA basically monitors retail meats
which are sampled from grocery stores.
So, you know, the pork chops, ground beef,
ground turkey, and chicken parts.
And, then also we've started
to pilot some new sample types in seafood and veal.
And, then the CDC, over on the right, they are responsible
for monitoring samples from humans that have become ill.
So the bacteria that are monitored are primarily formed
of the major foodborne bacterias.
Salmonella, campylobacter, E. coli, and enterococcus.
The CDC also conducts surveillance
of resistance among vibrio species other
than vibrio cholera and also shigella
and typhoidal salmonella from humans.
And, with regards to E. coli, CDC monitors,
in particular, the O157 strain.
Whereas, USDA, FSIS, and FDA monitor resistance among
generic, which means they're not serotype E. coli
from food animals and retail meats.
And, the generic E. coli are used by USDA and FDA basically
as indicator organisms to detect emerging resistance patterns
and even specific resistance genes
that could potentially be transferred
to other pathogenic gram negative bacteria
like salmonella.
But, in addition to monitoring antimicrobial susceptibility
patterns, NARMS also partners, you know,
their partners collaborate
on many epidemiologic investigations
and microbiologic research studies.
And, they also do, perform whole genome sequencing as part
of routine processes and analysis of salmonella
and campylobacter in addition to some sequencing
of resistant strains of E. coli and enterococcus.
But, so this is just a very brief summary of a lot
of very interesting stuff that NARMS does.
But, for information about how each of the three arms
of NARMS kind of conducts their sampling,
what antimicrobials are tested, what analytics are performed,
the reports that are produced, I have included some of the links
at the bottom of this slide where you can visit each
of their sites and get more information.
And, typically, NARMS does also produce an integrated report
where all three arms are presented together.
And, they will host, kind of, an interactive web based tool
for data activation too called NARMS Now.
Other examples of efforts to address antimicrobial resistance
in the human healthcare side of things, I just wanted
to very briefly touch on a few things with regard to many
of the activities that they have going on.
So antimicrobial use surveillance,
antimicrobial resistance surveillance,
antimicrobial stewardship.
So in terms of use surveillance, there's three main goals
for antimicrobial use surveillance.
And, basically, they can quantify
and describe the prescribing of antimicrobials,
help assess the appropriateness of prescribing, and also help
to measure the impact of interventions that were intended
to improve prescribing.
And, CDC in particular has conducted several facility-based
point prevalent surveys and have also used survey pharmacy
and medical claims data to really try
to describe U.S. antimicrobial prescribing
across the human healthcare spectrum.
And, also antimicrobial use and resistance modules
for hospitals have been incorporated
in the National Healthcare Safety Network.
Several antimicrobial resistance surveillance program also track
AMR among pathogenic bacteria isolated from humans.
I've only listed two here,
the Active Bacterial Core Surveillance
and the Emerging Infections Program, and then in addition
to the NARMS program which I had mentioned a few minutes ago.
CDC has also done a lot of work in the area
of antimicrobial stewardship for humans
and has published Core Elements which are essentially standards
for antimicrobial stewardship program implementation
in multiple settings like hospitals, long term care,
and outpatient settings.
And, an example of a state run program is actually the
Minnesota One Health Antibiotic Stewardship Collaborative.
And, this program really promotes judicious antimicrobial
use and stewardship across all sectors to really try
to reduce the impact of resistant pathogens in humans,
animals, and environment.
There are obviously many other efforts underway
in other states as well.
But, I just wanted to mention this one.
Animal agriculture and animal health, obviously,
also has been involved in many activities related
to addressing AMR.
I did want to just touch on a few, kind of,
relevant guidance documents that FDA has published.
For example, the FDA Guidance for Industry number 152.
Basically, this Guidance for Industry outlines kind
of a qualitative risk assessment process that FDA uses
to assess antimicrobial drugs that are intended for use
in food producing animals.
Looking at the risk in terms of development of resistance
and taking in the consideration of potential for human exposure
to the antimicrobial resistant bacteria through ingestion
of animal derived food.
FDA did also did publish Guidance
for Industry number 209 and number 213.
GFI number 209 basically outlined, in some detail,
principles for judicious antimicrobial use
in food producing animals.
And GFI number 213, the implementation
of which was completed as of January 1st 2017,
essentially limited the use
of medically important antimicrobials
in food producing animals to therapeutic purposes
and to those involving veterinary oversights.
And, in terms of medically important, we are referring
to antimicrobials that are important for,
medically important to human treatments.
And, just to mention, Appendix A
in the first Guidance I mentioned does list
out what the current medically important antimicrobials are
and what their ranking is.
So that's where that information comes from.
There are certainly ongoing efforts also
to collect antimicrobial use in animals
such as the USDA-APHIS Administered Antimicrobial Use
Surveys through their NAHMS program.
These were conducted in feed lot cattle and swine operations
in 2017 for data from 2016.
And, we also have some FDA Cooperative Agreements underway
which were awarded in 2016 to researchers
who are essentially piloting methodologies to collect
on farm antimicrobial use data from cattle, swine, and poultry.
And, then obviously I talked about NARMS already for,
in relation to the Antimicrobial Resistance Surveillance.
Just to touch on a few other programs,
I'll just briefly mention the FDA Veterinary Laboratory
Investigation and Response Network or Vet-LIRN,
as well as the USDA National Animal Health Laboratory Network
or NAHLN, which are both conducting pilot studies
to conduct antimicrobial susceptibility testing
for certain animal pathogens from companion animal
and food producing animal species.
And, in one of the projects conducting whole genome
sequencing on a subset of those isolets.
So just showing some additional efforts in terms of trying
to get some information about animal pathogens.
And, then in the environment,
there are basically efforts going on as well.
The U.S. Geological Survey
and U.S. EPA conduct ongoing water surveys basically trying
to get some routine sampling of streams, rivers, beaches,
and ground water systems to evaluate ecological health.
The USDA Agricultural Research Service
or ARS conducts extensive research to study the transport
and fate of resistant bacteria and soil
and other pre-harvest animal production settings.
And, a lot of the efforts
in the environmental sector are certainly focused on reducing
and controlling waste through stewardship
and waste management programs.
Just listed here some of the data gaps and research needs.
I know I already used more time than I was allotted.
So we can certainly circle back
around with any questions at the end.
But, it's fairly self-explanatory here,
from this slide, that we still need a lot of information.
And, in conclusion just wanted to, you know,
reiterate that AMR is a multifaceted and complex problem
that needs a One Health approach.
There are multiple efforts already ongoing
across the United States.
And, just also wanted to reiterate
that because antimicrobials are a shared resource antimicrobial
stewardship is also a shared responsibility.
Thank you.
>> Thank you.
Our next presentation, CDC's Antimicrobial Resistance Year
in Review Progress across One Health is by Dr. Dawn Sievert.
Please begin when you're ready.
>> Thank you.
Can you hear me okay?
>> Yes.
>> Great. Okay.
So again, I'm Dawn Sievert.
Thank you so much.
I really appreciate the opportunity to be here to talk
with all of you today.
I'm an epidemiologist.
And, my current role, I am Senior Science Advisor
for Antimicrobial Resistance a Coordination
and Strategy across the CDC.
So at a high level, in my brief presentation,
I'm going to just walk you through some of the main areas
and the work that we've done at CDC
to combat antibiotic resistance over this past year.
And, as Susan made clear, next slide please, why are we here?
Because antibiotic resistance is very clearly a One Health issue.
Any time antibiotics are used, they can lead to resistance,
even if it is very appropriate and needed and necessary.
And, we know, therefore, that this crosses all sectors
because antibiotics are used in people, animals, and on crops.
Next slide please.
So at the CDC, we work to fight antibiotic resistance,
again, across all sectors.
And, how do we do that?
So across healthcare we work to improve antibiotic use
and infection prevention with innovation and proven practices
to try to control spread.
When we work with foodborne illness,
we try to rapidly identify drug resistance foodborne bacteria
to stop and solve outbreaks and help improve prevention.
In the community space, we work to detect, prevent, track,
and treat drug resistant pathogens.
Internationally, our collaborations
and capacities are trying to improve surveillance,
infection control, prevention, stewardship,
and public health research.
And, as was mentioned by Susan, we are also, at the CDC,
working to explore the unanswered questions
about antimicrobial resistance and the interaction
between human, animals, and the environment.
And, to try to identify and figure out what that impact,
that true impact is with the environment.
Specifically, right now, we are focusing
on surface water and soil.
Next slide please.
So just this past September, we had an event celebration
in New York City to celebrate the end of a year of collections
of commitments called the Antimicrobial
Resistance Challenge.
And, this was an initiative with CDC and other partners
to bolster global effort across sectors and around the world
to set up, partner, and play their part in the fight
against antibiotic resistance.
And, what was asked of the group was how can you commit
from your space and the area and the work that you do to try
to combat antibiotic resistance?
What can you do?
And, with those groups who made commitments, they were asked
to focus on one or more of the following 5 areas.
So either the space of sharing data
and improving data collection.
Reducing the spread of resistant germs.
The improvement of appropriate antibiotic use including access.
Decreasing antibiotics and resistance in environment.
Or investing in the development and improved access to vaccines,
diagnostics, and therapeutics.
Next slide please.
This is very exciting.
This is what the numbers look like that we achieved
over this past year of collecting this commitment.
So from September 2018 through September 2019.
Can I ask, can you all still hear me?
>> Yes.
>> Okay. Great.
My phone made a very scary sound and I was worried.
Thank you.
So in one year, commitments from all 50 U.S. states
and Washington DC were collected including all state
health departments.
More than 75 commitments were made from 33 countries
and across 6 continents.
And, this will reach nearly 3 billion people around the world
as these actions and commitments are carried out.
Twenty six organizations representing
over 10,000 healthcare facilities globally pledged
to improve infection control or antibiotic use.
More than 47 major food and agriculture related corporations
and organizations committed to reducing
and preventing the spread of AR in animals and food production.
Forty seven organizations made commitments related
to improving safe drinking water, sanitation, and hygiene.
And, over 60 pharmaceutical biotech groups committed
to the development or providing access to products
that will prevent and treat resistant infections.
So very successful commitment collection
and a great celebration to identify and acknowledge all
of the groups that took the time to make the commitment
across the One Health sector.
And, we're very eager to watch the improvement,
the actions that are continued to carryout over the next 3
to 5 years and to follow up with all of these groups
to see the improvements that they're making
and how they're combating antibiotic resistance.
Next slide please.
The other area that we have been working very hard on,
and work has been done over the last 5 years,
has been with the National Action Plan
to combat antibiotic resistance.
And, this has been an effort across federal agencies,
all the federal agencies in the U.S., with a specific set
of goals and objectives.
And, the agencies then all identified action with measures
that we would all be able to put forth and follow
to track the work that we're doing to improve the work,
to combat, and to try to decrease the spread
and transmission and creation,
development of antibiotic resistance.
So those goals for these past 5 years have been focusing
on slowing the emergence of resistant bacteria,
and preventing the spread.
Strengthening the One Health surveillance efforts.
Advancing development and use of rapid
and innovative diagnostic tests.
Accelerating basic and applied researcher and development, and,
this would cover new antibiotics,
therapeutics, and vaccines.
And, improving our international collaboration and capacities
to move other countries along that may be a little bit behind
or may need additional assistance with working
on AR prevention, surveillance control,
and also research and development.
Next slide please.
So we're now coming to the end
of the first 5 years of all of this work.
And, so CDC, with others,
all the other federal agencies have been working now
to review those five goals and the objectives under them
and to make any revisions that are necessary.
And, then for us to be able to work, over thee next 5 years,
on new measures and new action.
So hopefully, and what has been the case is that many
of the actions that we all put forth
over the past 5 years have been achieved.
There's still much work to do, but, realistically,
when actions were named, many of them were supposed
to be completed, things were supposed to be started and put
in place to grow from.
And, we have achieved,
across several agencies, a lot of that work.
So now we're looking at where the gaps exist
and what do we need now to do to accomplish additional work
and to close those gaps over the next 5 years.
So the President's Advisory Council
on Combating Antibiotic Resistance was one group
that requested public feedback on this next iteration
and they put forth a report that we've been working on
and following as we look at these goals and objectives
to revise them for the next 5 years.
They, and so at CDC some of these, all of these
that are listed here are our main focus for us on the work
that we'll continue to do at CDC
and how we'll work with our partners.
So that includes things like continuing to advance the use of
and the work that the National Healthcare Safety Network does.
And, NHSN collects data on antibiotic resistant infections
from healthcare associated infections
across many different types of healthcare settings.
Also the work that we're doing with acute care
and other settings on antibiotic stewardship to advance
and help human health.
The work that the National Antimicrobial Resistance
Monitoring System does at the CDC
on human enteric illness tracking, and,
Susan gave a good explanation of NARMS,
so this for our focus is the human enterics on the CDC side.
The other two cover the work that we do
with state health departments and specific state sites
through the ELC Cooperative Agreement
and the Emerging Infections Program
and very specifically funding them for follow-up on outbreaks
and investigations and tracking unique
and emerging antibiotic resistance in their areas,
and then sharing those data with us
so that we'll have a better national representative picture.
So throughout this year, again, CDC's been helping and working
with other federal agencies.
The, again, the CARB plan will end in 2020
from these past 5 years.
So the transition will occur.
The new plan will be finalized in early 2020.
And, we'll be looking all to begin that work by early 2021,
we're excited now for the next five years of work.
And, I know that all of you will be hearing more
about that as that draws closer.
The next thing I wanted to describe and explain to you is,
in addition to all the work I named above and how we work
with state health departments and specific funded sites,
we also try very hard to open up the work that we do
and advance the work that we do to help us move this work
and effort forward against of antimicrobial resistance
with academia and professional organizations
and other groups like that.
And, the way that we are able to get money out to work
with those groups to expand our research is
through what we call the Broad Agency Announcement Funding.
I'm sorry I didn't say next slide but I'm on the BAA slide.
And, so what the BAA's are is announcements from CDC
to identify gaps in knowledge or areas
that we need more information.
And, we cannot do all of that work clearly
at the CDC by ourselves.
We need many partners and collaborations.
And, so we identify a lot of, a list of work
that gets announced usually around November and December.
And, then partners who are interested can look
at specific topics and write proposals
for how they would propose to address that gap
or that issue or that need.
And, then can review process by the end of that summer
through funds that we have.
Then we are able to identify the highest ranking score proposal
and then fund those for, usually they are 12
to 24 month projects.
We've done this every year for the past 3 or 4 years.
This year there will not be an announcement that goes out.
We're in November now.
So clearly there won't be an announcement that goes
out November, December this year.
We're going to be moving to every other year.
So projects will continue 12 to 24 months
and overlap each other.
But, we'll be putting this announcement out then next year.
So next year at this time, we'll be excited
to put forth another announcement
to start gathering new proposals from interested participants.
But, so far, CDC's provided about $110 million in research
in piloting to 96 public,
private institutions both domestically and globally.
And, this reflects 158 applied public health research projects.
And, again, all around antimicrobial resistance.
CDC supports innovations and collaborations
with investigators to identify and implement new ways
to present antibiotic resistant infections and their spread.
And again, as I mentioned,
the awardees included educational institutions,
nonprofit organizations, state and local government,
and private industry for research and development.
If you are interested, we invite you to go
to the website that's shown on the slide.
And, what it does is list all of the participants,
the applicants who've been funded so far.
So it will show the institution, it will show the topics
that we're working on.
And, as we continue to update the website,
it also will show publications that come
out of the great work that's being done and the findings
from all the work that we've funded.
So please continue to take a look at that site
for information on the type of work that's being done
and accomplished through that BAA's.
The next slide please.
So I'm very excited.
And, this is almost our last slide.
So this is the last of these slides, we're very excited.
This is things that are up and coming now, basically.
So the CDC 2019 AR Threats Report that we are very excited
about is actually expected out before the end of next week.
So it's perfect timing to be able to announce this to you
and let you know about it so you can watch for it.
There'll be a lot of information coming out,
once the press release is out and the embargo is released.
And, so by the end of next week, you'll hear information
about the new CDC 2019 AR Threats report.
This is the second report that we are putting
out to identify important antimicrobial resistant
pathogens that seriously effects human health.
And, it crosses all of the pathogens that we follow
across CDC, so again across the One Health spectrum.
CDC published the first report in 2013
and it was a comprehensive analysis
that ranked 18 top AR threats in the U.S. And,
this was the first time,
really that the CDC clearly raised the nation's awareness
about antibiotic resistance and the specific pathogens
that we were dealing with at CDC.
So the 19 report follows a similar format but updated.
The preliminary data, I can tell you,
do show that prevention is working
but more work is clearly needed, especially globally.
So our work is not anywhere near being done.
But we do see through the data that the efforts
that are put forward do work.
And, so it's exciting to know that,
when we do put those effort in, we do get to see improvements.
The overall highlights of the new report are that we always,
at CDC, and there's going to be a big explanation
in the methodology about how we even try to improve all the data
that we have at CDC, to better calculate estimates
for this report compared to the 2013 report.
The assessed threats do use the same 3 categories which are,
sorry, they are urgent, serious, and concerning.
But, this report in 2019, we have some new pathogens
that made their way into the urgent category.
So from 2013 none of the organism left urgent.
I believe none of them have been downgraded.
But some additional ones have been added.
So again, our work is not done.
We've analyzed data to provide some changes over time.
So we do have trend data for some of the pathogens
when that capability was available for us to do .
We have new information in the reports list.
One thing that's new added
to the report this time is a watch list.
So there's 3 pathogens that are named.
The watch list is basically, we see at CDC some small emergence,
we might see it, we'll be watching it globally.
We might get indications of it domestically.
But, we don't have full surveillance set up for it.
But, we see that this might be a concern.
So we're naming them now to indicate
that we'll be watching them more carefully going forward now.
And, then we will see, hopefully,
they won't hit the top 18 list when we do the next report.
But, the indication is we may be seeing them
on the list the next time we have a report.
We also have spent a lot of time identifying some
of the data we know, also the scientific gaps
that still exist.
We identify successful actions that have been taken
and additional actions that are still needed.
And, the same from the 2013 report, this again I said covers
across all of CDC, healthcare associated infections,
tuberculosis, STD's, respiratory, enteric,
and fungal infections.
So a broad comprehensive report from the CDC
on antibiotic resistant pathogens.
Once the report comes out, next slide please,
you will also be able to follow the Antimicrobial Resistance
website at CDC and all the specific websites
of the division that cover the pathogens included.
And, you're going to see all those data being updated
to make sure that they all match the data that are
in the Threats Report.
You'll also see that we start making changes to make sure
that the One Health focus is very clearly identified
and apparent on our website.
So they all know that we are working
across the One Health spectrum when we look at AR at the CDC.
We'll have new and updated infographics,
a lot of which will be included and found in the Threats Report
and broader reached audiences, new groups that we really want
to work more closely with.
And, that includes groups like veterinarians
and food production industry, animal industry.
Finally, following that,
the week after next is U.S. Antibiotic Awareness week.
So from November 18th to 24th, it's coming up.
And, you will see, you'll be able to follow on the website
and through Twitter, you'll be able to see what we're talking
about from CDC which regards antimicrobial resistance
and how we're trying to combat it.
And, again, because the Threats Report is coming
out right before that, there'll be a lot of talk
around the Threats Report.
So for that I thank you, I thank you for your attention.
I look forward for any questions after our next speaker.
Thank you.
>> Thank you.
Our final presentation, USDA Agricultural Research Service:
AMR and Alternatives to Antibiotic Research
Across the One Health Spectrum is by Dr. Roxann Motroni.
Please begin when you're ready.
>> Thank you very much.
And, thank you everybody.
My name is Roxann Motroni.
I'm the National Program Leader
for Animal Health where at USDA ARS.
And, I co-lead a lot of our AMR activities
with Dr. Kim Cook who's the National Program Leader
for Food Safety.
So I'm excited to talk to you today about some of the research
that ARS does as it relates to AMR and the One Health spectrum.
So I just quickly wanted to point
out that ARS is really a research organization.
Oops sorry.
Don't know what happened to the slides there.
Ah oh.
>> I'll fix it just hang on one second.
>> Oh okay.
Well, I'll just continue
that USDA ARS is really a research organization.
We fall under the research education
and economics undersecretary.
And, so our goal is really to provide research.
We're not a regulatory agency like APHIS
or Food Safety Inspection Service, though we work
with them quite regularly to inform some of their regulations
through scientific evidence.
And, so that's really our mission area.
We're also not a granting agency like the National Institute
of food and Agriculture or NIFA.
And, that is more the extramural research arm of the USDA.
Okay. I'm going to try and advance the slides.
Okay. So ARS, as I said before,
is the intramural research arm of the USDA.
And, our job really, and our mission is to provide solutions
to agricultural problems
by conducting solution oriented research.
We have about 700 research projects
across 16 national programs.
And, that stems everything within agriculture
from natural resources to plants, to food safety
to animal health and production.
We have about 2,000 scientists and post docs and we have
about 1.3 billion fiscal year budget.
We also have about 90 research locations
across the country including overseas laboratories
that do bio control.
So we are a fairly large and disparate organization.
So I think both Dawn and Susan really covered it well
to show that, when you're talking about One Health,
in particularly AMR, it's pretty complicated.
And, when you look at it there are many different drivers
from the human health side, from the animal side,
and the environmental side.
And, so ARS really does a lot of research in many
of the agricultural impacted environments to try
to get an understanding of how does AMR move in all
of these different environments.
How is it transmitted?
How does it persist?
And, then the development of mitigation strategies.
So one of our program groups are Natural Resources
and Austainable Agricultural Systems.
There's quite a bit of research in terms of the soil microbiome,
manure treatment, waste water treatment, and understanding
of rivers and lakes, irrigation practices.
Our Nutrition and Food Safety and Quality, as you can imagine,
they do quite a bit on the food safety side,
so the pre-harvest food safety side working in slaughter houses
with livestock, milk and eggs.
Looking at processes within slaughterhouse environment
and those mitigation strategies.
And, then the Animal Production
and Protection program does research in terms
of aquaculture, understanding and trying to prevent disease
within our aquaculture species as well
as within our livestock species.
So I can't really go into everything
that ARS is doing related to AMR research today.
So I'm just going to kind of give a broad overview.
But one of our big areas that we're placing emphasis
on is an alternative to antibiotics.
With a goal to provide solutions that allow for prevention
and treatment of diseases in our livestock species
but don't result in creating selective pressure
for the development of antimicrobial resistance.
And, then to allow practitioners in the livestock industry
to therefore optimize their antibiotic use.
We are focusing a lot of our alternatives to antibiotics
for priority production diseases
that often require antibiotic treatment.
And, so much of this is determined in conjunction
with the OIE as they came out with two reports,
one for poultry and swine species
and then one for ruminant species.
And, so we use that list to help decide what diseases we are
working on as well as important food safety pathogens.
And, so our alternatives to antibiotics are really focused
on novel antimicrobials that do not select for resistance,
bacteriophage, bacteriophage gene products, essential oils,
immune enhancers, innate defense molecules, lytic enzymes,
organic acids, phytochemicals, prebiotics and probiotics,
interfering RNA's, therapeutic antibodies, and vaccines,
so many of the technologies that I think they're also talking
about on the human health side.
We are also doing quite a bit to look for genetics
in the host species that might be associated
with disease resistance so that antimicrobials don't have
to be used when an animal has an infection.
And, I should also say that we're working
in precision livestock technologies as well.
So looking at ways in which we can identify sick animals
earlier so that they can be pulled out of pens
and treated appropriately prior to spreading disease
to other animals within the herd.
So one of our examples
of an antibiotic alternatives are Egg Yolk IgY.
So necrotic enteritis in poultry is one
of the main reasons why antibiotics are used in poultry.
And, so it's been a big push to develop other therapeutics
that could be used to prevent this disease.
So Dr. Hyun Lillehoj in Beltsville Maryland has figured
out a way to hyper-immunize chickens which causes them
to secret a large amount of IgY antibodies
into their eggs and their egg yolks.
And, you can actually harvest the eggs and dry the egg yolk
and get the IgY back out which you can then feed to chickens
that are at risk to developing necrotic enteritis
to prevent the disease.
And, so this is a really, I think a really novel way
of being able to treat poultry
in an environmentally friendly way that is also a technology
that will not result in increased resistance
and will hopefully benefit the animal health
and the animal welfare of poultry.
Additionally, we are, we have some projects that are looking
at antimicrobial resistance in swine and animal pathogens
as well as human pathogens.
So one of the big ones being Methicillin-resistant
Staphylococcus aureus, was in the news quite a few years ago.
And, so Dr. Tracy Nicholson
at the National Animal Disease Center
in Ames Iowa started looking
at how similar different islets were between swine
and human health or human clinical settings.
And, she found that MRSA found
in agricultural sources were very distinct
from those obtained from human clinical settings.
And, she also wanted to look at, since zinc is often fed to swine
as an antimicrobial, whether or not that could be selecting
for resistance in large animal associated MRSA.
And, she found that actually the zinc, the prevalence
of zinc resistance in large animal MRSA was lower
than the prevalence of zinc resistance in human isolets.
And, so it's likely that zinc supplementation did not actually
play a significant role in the emergence of large animal MRSA
in the swine population.
Also, we have, within our food safety programs, we have a lot
of people looking at different management practices
and their impact on antibiotic resistance.
And, so Dr. Michael Rothrock is
at the U.S. National Poultry Research Center
in Athens Georgia.
And, he's looked at pastured poultry that are raised
in an antibiotic free environment and trying
to characterize the resistance in bacteria found
on the farm within the birds.
And, he found that, really,
you still find multi drug resistant bacteria and that just
because something is antibiotic free doesn't mean
that they're antibiotic resistance free.
And, he also found that E. coli are a poor indicator
of antibiotic resistance.
So moving to another part of the One Health spectrum,
I think there's much more emphasis being placed
on the environment and the role of the environment.
And, so one of the big questions that is
out there is what does the baseline resistance look like?
And, how do we characterize what baseline is in the environment?
And, so Dr. Terry Arthur at Clay Center Nebraska wanted to look
at how, wanted to start trying to address that question
with the idea of how do you then look at the impact
of different things that you add to the soil,
so like manure, fertilizer, etcetera?
And, how does that change what you see in terms
of antibiotic resistance genes?
And, so what he found was that, really,
when you add any nutrients to soil, you see an increase
in the level of resistant bacteria.
And, so that, you have to take that into account
when you start looking or start trying
to develop environmental baselines
because whether you're adding just straight broth or manure
or anything, you're probably going to change the level
of resistant bacteria.
And, that's really going to be important to know as you try
to look at the movement of these genes through the environment.
So since we're an intramural research agency,
we basically get all of our funding from Congress
and are directed with what we are able to study.
But, we've been able to set aside some intramural funding
and have an intramural RFA for projects with the idea of trying
to foster multidisciplinary and cross programmatic projects
that are high priority so that we can be more responsive
to what's out there.
And, I think I've shown that ARS has a very broad spectrum
of scientists working in this area.
So what we're really trying to do with this program is
to bring our scientists together to try
to get a better understanding of what's going
on in the bigger picture.
And, so last year we received 44 proposals
and we were able to fund 17 of them.
But, as you can see from the list, I think we were able
to fund a lot of different projects and a lot
of different topic areas.
So one of the first ones
that I think is very exciting is looking
at our Human Nutrition Center, is looking at the effect
of different diets on the microbiota and on the resistome.
And I think that will be a very interesting study
or the results we're excited to see.
We're also keenly aware of animal welfare and the removal
of antibiotics maybe having a detrimental impact
on animal welfare.
So trying to figure out what are other things that can be fed
to pigs or to other species to try
to mitigate some of those impacts.
And, that's happening at our research team
in West Lafayette Indiana.
We have projects working on development for vaccines
in aquaculture and other alternatives to antibiotics
as well as within the crop side.
We have projects working on priority pathogens,
both on the food safety side as well as the animal health side.
And, as I said before, alternatives
to antibiotics are a big topic for us.
And, so we're looking at developing or trying
to develop preventives or therapeutics for some
of these priority pathogens that require antibiotic use.
And, then to round out the One Health spectrum,
we have products looking at water, air, soil and looking
at trying to develop mitigation strategies
to disrupt gene transmission in the environment.
So finally, we are hoping to come
out with an accomplishment report later this year
so that you can see, on the much broader spectrum,
all of the things that ARS is doing research in.
And, so I can keep you posted on that.
We also are hosting the Third International Symposium
on Alternative to Antibiotics in Bangkok, Thailand.
And, that's in December of this year.
And, that is held in collaboration with the OIE.
Dr. Cyril Gay is the one who's organizing that.
And, so his email is below if you're interested in the website
for the symposium, it's also listed on the side.
And, with that I say thank you.
And, the links on the bottom on the page were
for more additional information on ARS's AMR program.
With that, thank you very much.
>> Thank you.
Unfortunately, we've run out of time for questions.
Thanks to all these great presentations.
But, you can email your questions to the presenters.
You'll find that email addresses
on the ZOHU Call web page for today's call.
Thanks again to all of today's speakers
for their excellent presentation.
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