Updates: There’s a lot coming out of the summit today, so I’m breaking up this piece with subheads. Here’s a menu; I’ll add links over the course of the day:
- Introduction to the summit
- Official video, statements, lists of attendees
- Report on the opening session
- Outside commentary
- Commitments or statements by organizations participating
Representatives of more than 150 health care organizations, medical schools, pharmaceutical companies federal health agencies and food-production interests will meet at the White House today for a day-long “Forum on Antibiotic Stewardship,” the first of its kind. The Forum is a day-long meeting, to be held mostly out of the public eye, in which the Obama Administration plans to press the companies and organizations to commit to plans to reduce and conserve antibiotic use, in order to slow down the advance of antibiotic resistance.
Putting its own marker on the table, the White House announced this morning that it is directing federal departments to begin purchasing meat and poultry raised with what they called “responsible antibiotic use,” a term that is going to take some unpacking but that probably means in accordance with the reduced-antibiotic use policies that the Food and Drug Administration has been pushing forward since last year. In an announcement posted this morning, the White House said the purchasing plan would have work on a five-year timeline, ending up in 2020 with “applying a preference” for antibiotic-free meats.
The summit follows on a suite of other actions the administration has taken to combat resistance, which according to data from the Centers for Disease Control and Prevention kills 23,000 Americans each year and sickens more than 2 million. (The UK-based Review on Antimicrobial Resistance estimates that the worldwide toll is 750,000 deaths a year, and predicts it will rise as high as 10 million.) Last year, the administration issued a national strategy for combatting resistance, along with an executive order signed by Obama, and a lengthy report by the President’s Council of Advisors on Science and Technology that set forth explicit steps each agency and the private sector should take. (My past coverage: long explainer, earlier posts.)
In a press briefing Monday evening, Amy Pope, the deputy Homeland Security advisor, said the summit today is intended to push those efforts along further, by bringing to the table the entire range of entities involved with any aspect of resistance, and getting them to make explicit (though voluntary) commitments to taking action.
Here are a few of the commitments, according to a White House fact sheet released this morning:
- Hospital Corporation of America: agrees to develop computerized decision-making tools for tracking lab results, highlighting the emergence of resistance in patients, and choosing the best prescriptions;
- Intermountain Healthcare: commits to reducing inappropriate outpatient antibiotic use by half;
- Pediatric Infectious Disease Society: will ensure that hospitals that usually cater to adult patients will have stewardship education tools that address the different care and prescription needs of kid patients;
- BD Diagnostics: will develop rapid tests for CREs, the almost completely resistant superbugs that have been spreading through hospitals across the US for 15 years.
There is likely to be a lot of attention paid to the commitments being made by food-production and food-service companies, because in the push to reduce resistance, agriculture and veterinary pharma have resisted change. On the summit invitation list are a number of food companies that have recently made striking commitments to change their practices, including McDonald’s, Tyson, Walmart, and Smithfield, along with Foster Farms, which just yesterday announced antibiotic reduction policies.
Speaking during the briefing last night, Dr. Thomas Frieden, director of the CDC, said: “Tomorrow is a really important day, because antibiotic resistance is a really important problem.”
I’ll update with ongoing coverage and links throughout the day.
Only the opening 90 minutes of the day-long summit was open to the press (and public, via webcast). The video, on the White House’s YouTube channel, is here.
Here is the White House’s fact sheet on the summit, with a list of attendees (just organization/corporation names, no listing of individuals) and a sampling of the commitments some of them have made to support stewardship. I’ll excerpt those later.
CDC Director Tom Frieden placed an explanatory op-ed in the Wall Street Journal this morning.
The public portion of the summit featured the sort of statements you expect from senior government officials, but even within those, there were some surprises. Those statements were followed by a panel featuring five of the 150 or so attendees, carefully chosen to represent the range of players in this complex issue: Healthcare Association of America (hospitals); Genesis Healthcare (nursing homes); Elanco (animal drugs); Walmart; and Tyson Foods. Walmart and Tyson are two of several food companies that got out news of their changes in in advance of the summit: Walmart establishing a broad animal-welfare policy, Tyson committing to reduced antibiotic use.
The first speakers at the summit were agency chiefs: John P. Holdren, director of the White House Office of Science and Technology Policy; Sylvia Burwell, Secretary of Health and Human Services; Frieden, director of the CDC; and Tom Vilsack, Secretary of Agriculture. But the importance of the event was best-defined by the last speaker: Lisa Monaco, Homeland Security Advisor to the President.
Combatting antibiotic resistance, she said, “is vital to our security, our public health security, here in the United States and around the world… This is not a problem that any of us can afford to kick down the road.” Quoting Obama, she added: “It is a challenge we have to take seriously, and invest in now.”
Several pieces of hard news were announced at the start. First, Holdren said that the White House has already begun serving only meat raised without any hormones or antibiotics. That’s in addition to the 5-year plan for moving government procurement to “preferring” meat raised with responsible antibiotic use, in the Introduction section above, and is a more strict standard: antibiotic-free, as opposed to animal-only antibiotics, or antibiotics used judiciously.
Second, Burwell announced big dollars to stimulate innovation: a $20 million federal prize for achieving a “rapid point of care diagnostic test,” that is, a new piece of technology that could be used in a doctor’s office or at a patient’s bedside to diagnose which organism is causing an infection and what drugs it is resistant to. Tests like these are expensive to develop, and crucial to achieve in order to make sure that the right drugs are prescribed from the start; inappropriate prescriptions push disease bacteria toward developing resistance. (For those following international antibiotic policy, this is similar to the Longitude Prize in the United Kingdom, which offers £10 million toward the same goal.)
And third, via Burwell, the FDA announced the long-awaited final version of its Veterinary Feed Directive, a regulation that requires livestock producers to consult veterinarians before using antibiotics on their herds and flocks, and gives veterinarians tight control over which antibiotics are used. This changes the long-existing set-up in which many antibiotics could be purchased over-the-counter by farmers and used without any outside advice, and requires a farmer to have an existing relationships with a veterinarian and to obtain prescriptions before using most drugs. The VFD, as it’s called, is a companion piece to two voluntary guidances issued by the FDA in late 2013, which address phasing out of growth promoters, the tiny, routine drug doses blamed for contributing to the emergence of antibiotic resistance. But, unlike those documents, the VFD is a rule with the force of law, not just a strongly worded but non-binding recommendation.
Following the officials’ appearances, the five representatives of the various constituencies in the antibiotics-use problem assembled as a panel moderated by CDC Director Frieden. Some extracts from that (consult the YouTube link for the full session):
Some of the barriers to combatting antibiotic resistance could be handled today with no new technology—just increased commitment. Dr. Jonathan Perlin, chief medical officer of the Hospital Corporation of America (with roles at the American Hospital Association and the Department of Veterans Affairs), on barriers to combatting resistance, said: “If… I could choose one thing to do in the rest of (my) career it would be effective hand hygiene. We don’t need to be vectors of transmission of infections inadvertently. As health professionals, it is unacceptable that we may not be as good as passengers on a cruise ship in terms of the consistent use of good hand hygiene. That is a barrier: We are not as good as we need to be.”
Improving agricultural antibiotic use is a matter of persuasion and reassurance as well as regulation. Frank Yiannas, vice president of food safety at Walmart, said: “If you think about a food system of producers who have been doing something the same way for many years… if you ask them to change, there will naturally be questions: Will I see the same yields, the same efficiencies?” He added that to move toward better antibiotic use, companies working on the problem need to be transparent about their operations and to share information about what has worked for them.
Donnie Smith, president and CEO of Tyson Foods, said food companies are realizing there is a business case to be made for antibiotic conservation. (Tyson recently made a broad antibiotic-reduction commitment.) “We’ve found there are cost-benefits in the mechanisms we have put in place to reduce the use of antibiotics. Often, drugs that are not broad spectrum are cheaper to use. We can find ways whether though husbandry, the technology of modern animal housing… Anything we can do to reduce concern on the consumers’ behalf regarding the food they choose is good for all our business.”
And, making a startling financial commitment, Jeff Simmons, president of drug-makers Elanco Animal Health, said the company would redirect two-thirds of its food-animal pharmaceuticals budget toward discovering “non-antibiotic” alternative formulas, and in one year would host an animal health accountability summit” to share information on research efforts. “We have 25 candidates in our pipeline that are non-antibiotics, and our goal is to deliver 10,” he said, listing “vaccines, immune modulators, enzymes and novel therapies” as possible antibiotic replacements.
Following the public session, the attendees were divided into two private breakout sessions, one focusing on human health and the other on animal health. I’m told that in the days leading up to the summit, there was a lot of concern expressed by advocacy and consumer groups who have been working to reduce agricultural antibiotic use that they would not be allowed into the animal-health session, where reduction of farm antibiotics was under discussion. This concern was captured by a statement released this morning by the advocacy umbrella organization Keep Antibiotics Working. Their policy analyst Susan Vaughn Grooters said in part:
…we are troubled by the fact that most of the consumer advocacy organizations that have been working to combat antibiotic resistance related to animal agriculture, some for decades now, were not invited to participate in today’s White House summit.
￼￼￼￼It is telling that today’s Forum is highlighting policies from Tyson Foods and Perdue (which are responding to consumer demand that food animals be raised without the use of routine antibiotics) to validate the [FDA’s] much weaker guidance, which continues to allow medically-important antibiotics to be used on a routine basis. While a handful of chicken producers have taken significant steps to reduce antibiotic use, beef, pork, and turkey producers have not. …The White House’s efforts may provide cover for these sectors as they resist real change.
And in fact, representatives of organizations who work on the human impact of animal antibiotic use found themselves assigned this morning to the human health side, with no ability to give input to the ag-antibiotics session.
On a lighter note, the summit was catered by Panera Bread, which was mentioned in the morning session for expanding its commitment to antibiotic-free raising beyond chicken (the focus of most companies’ efforts) to eggs and hogs, and to committing to grass-fed beef.
In an early reaction, the Natural Resources Defense Council criticizes the just-announced federal procurement policy for meat for not going far enough, and allowing a loophole that will permit some key antibiotics to still be used.
To coincide with the summit, the nonprofit Center for Disease Dynamics, Economics and Policy created a complex interactive timeline that makes the case for stewardship (and the need through new drug development) by tracking the dates when key antibiotics were introduced to the United States, and their usage and sale patterns since. The timeline’s data-rich arcs document how use has declined as some antibiotics became ineffective—and how use is soaring for the few remaining antibiotics that still work.
I’ll add these as I find or receive them. Also consult the White House fact sheet for additional commitments by organizations and companies.
Alere (rapid diagnostics)
Association for Professionals in Infection Control and Epidemiology (infection control in hospitals)
Association of Public Health Laboratories (strengthening surveillance for resistant bugs)
Consumer Reports (human and animal misuse)
Keep Antibiotics Working, a coalition of public health groups (animal use, and criticism of underrepresentation at the summit by consumer and advocacy groups)
Panera Bread (antibiotic-free meat)
Pediatric Infectious Diseases Society (the mismatch between adult and pediatric antibiotic needs)
Pew Charitable Trusts (data project on antibiotic overuse)
Society of Hospital Medicine (urging hospital-based physicians to educate patients)