Author Archives: Prof Ramon Z Shaban

About Prof Ramon Z Shaban

Professor Ramon Z. Shaban RN CICP-E IPN EMT-P BSc(Med) BN PGDipPH&TM GradCertInfecCon MCHealthPrac(Hons) MEd PhD FACN FCENA Professor Ramon Shaban is the Inaugural Clinical Chair and Professor of Infection Prevention and Control at the University of Sydney and Western Sydney Local Health District, within the Sydney Nursing School and the Marie Bashir Institute for Infectious Diseases and Biosecurity. As a credentialled expert infection control practitioner and emergency nurse with a background in clinical and medical sciences, his expertise in infectious diseases, infection control and emergency care are the basis of a highly successful and integrated program of teaching, practice, and research. Professor Shaban is the Immediate President of the Australasian College for Infection Prevention, a statutory member of the Australian Government Strategic and Technical Advisory Group on Antimicrobial Resistance, Editor-in-Chief of the Australasian Emergency Nursing Journal, and a Senior Editor of Infection, Disease and Health. In 2016, he served as Technical Advisor (Antimicrobial Resistance) with the World Health Organization. He previously established and served as the Inaugural Clinical Chair of Infection Prevention and Control at Griffith University and Gold Coast Health Hospital and Health Service, the first of its kind in Australia. He was the Director of the Griffith Graduate Infection Prevention and Control Programs at Griffith University from 2005 to 2017.

Making antimicrobial resistance and the control of communicable disease, like infection control, is really everyone’s business.

As I reflect on another year, there have been many headline issues in infection control and communicable diseases. One headline was arguably the brightest, loudest and most prominent—antimicrobial resistance. In many respects 2016 was the year for antimicrobial resistance (AMR). The march of resistance and the grave concerns therein, particularly with the spread of carbapenem-resistant Enterobacteriaceae or CRE, have focused the attention of many. Global recognition and focus came via the United Nations as well as multi-national whole of government emphasis of AMR as a priority in the United Kingdom, the United States and other countries around the world. The year also saw a much-needed corrective global focus and attention on access and excess rather than overuse and misuse. All made for interesting times for clinicians, patients and consumers, and society in general. It also makes for interesting times for what comes next. In considering the priorities for research and innovation, the following seem to me to be some of the important focal areas for the future:

One priority focal point should be the formal designation of the control of communicable diseases, the spread of infection and antimicrobial resistance as societal, political, health and research priorities within a One Health approach. As we have seen, the United Nations declared AMR as a global health priority, only forth health priority to be so declared. The WHO and its many divisions applied renewed focus of AMR around the world. The United States and United Kingdom has posited AMR squarely as a whole-of-government and whole of society issue. Others have followed suit in various forms. Doing so matters. Such declarations matter. They transact change. Such designations focus the efforts and attention turn of governments, NGO, researchers, funding bodies, industry, clinicians, educators and society more broadly. Some doubt the significant and weight of such declarations as declared health and/or research priorities. To those I say try de-designate an existing health or research priority that has unfinished business and see what happens. For example removing cancer from Australia’s list of national health and research priorities would never be entertained, and any attempt would attract unanimous condemnation. The new and impressive Australian Medical Research Future Fund and Australian Medical Research and Innovation Priorities 2016-2018 have AMR and the control of communicable diseases as core priorities. Such designation is commended, but more is needed. AMR should be a national designated national health priority, as it is one issue that underpins so many health areas. It also underpins the fabric of society.

Another focus should be the acceleration and expansion of infection-excluding diagnostics and technology. While technology and resources for rapid and definitive diagnosis is the ultimate goal, excluding infection attributable injury and disease that has a reliance on antibiotics would go a long way to reducing our use of antibiotics. 

Closely related to this is the need for intense and considered focus on new and renewed countermeasures. This should include, but is not limited to, One Health vaccine development for conditions that have reliance on antimicrobials, drug discovery, rapid definitive diagnostics at both bench and bedside, utility of non-classic pharmacological interventions such as bacteriophages, and the standardisation of laboratory testing.

Moreover, we should focus on extending the evidence and practice base that is we know works (or not as the case may be) in human health and non-health related context into animal, agricultural and environment sectors for a truly One Health approach. Is it not time equivalent of the Five Moments for Hand Hygiene for veterinarians?

Finally, and not before time, it’s time cast of the armoury of own specialist professions and embrace the many in non-clinical professions, and call upon them to join be part of the solution to AMR. It is high time we harnessed existing and new knowledge into human factors and behaviour modification to bring about whole of societal change within a One Health approach. This should focus on existing evidence base for non-infection control and non-health to effect changes in human factors for reliance on antibiotics for all populations across the lifespan and across One Health. So much is known about behaviour change in the non-health areas, as marketing and behavioural sciences. It is difficult to see how these cannot be applicable (or relevant in some form) to AMR. What we can learn from our non-clinical peers about changing people behaviours from the commercial work is enormous. Moreover, such focus must be across the spectrum of disease and illness including prevention, treatment, rehabilitation and coalescence.

AMR is not, and can no longer be considered, a problem for just for clinicians both human and veterinary, and industry to solve. It is a whole of society challenge, and many of the solutions are non-clinical. It, like infection control, is everyone’s business.

 

The ‘I’ and the ‘We’ of antimicrobial resistance

 

Not a day goes by where there isn’t a report somewhere about the threat of antimicrobial resistance. Our media is awash with grim stories about ‘superbugs’ emerging in patients and hospitals, with dire predictions about the future of healthcare and even humanity and the planet as we know it. There is much that we know about antimicrobial resistance. We know that antimicrobial resistance is a significant global health and security threat. We know that it is something that is increasingly the focus of the work of busy infection control professionals, ID physicians and pharmacists. We know that governments, non-government organisations and all manner of other organisations and groups around the world are marshalling resources, and launching campaigns and strategies to slow the pace and spread of antimicrobial resistance. We know that use of antimicrobials is the primary driver of resistance, and we know that this is accelerated by what is commonly described as overuse, misuse or inappropriate use.  We also know that there is considerable international evidence demonstrating the relationship between antibiotic overuse, misuse or inappropriate use of antibiotics and resistance, and we know the kinds of very many problems that arise from this. Recently here in Australia the First Australian Report on Antimicrobial Use and Resistance in Human Health[1] by the Australian Commission on Safety and Quality in Health Care documented the extent to which Australia has contributed to the rise of global problem. The news this report brought was mixed: in some areas it was cause for celebration; in others our worst fears were realised. We know there is much, much more work to be done.

There are other aspects to this, however, that are not well known to all. There are aspects of this that ‘we’ don’t know well or appreciate. We tend of overlook, forget, and even not appreciate that for millions of people around the world the concepts of antibiotic overuse, misuse or inappropriate use are completely alien.  For millions and millions of people around there world there is no access, or very limited access, to antibiotics. Antibiotics are precious commodities that many only dream of having. In their recent commentary in The Lancet Pamela Das and Richard Horton argued that focusing on resistance in terms of misuse or overuse fails to take a global perspective on the needs of the many for whom antibiotics are a precious resource.[2] As they rightly point out, we tend to overlook, or lack an appreciation for, the fact that many more people die from the lack of access, or delayed access,to antimicrobials than from resistant organisms. While this stark reminder should of course in no way serve to discourage efforts to more prudent use of antibiotics in settings where overuse, misuse or inappropriate use occurs, we must also turn our minds to how we can bring about both sustainable access and sustainable effectiveness for all. We must enhance non antimicrobial-based initiatives to reduce the burden of disease, such as immunisation to improve health outcomes with a system of Universal Health Coverage. We know that this is but one critical intervention to realising the efforts for our wider goal to conserve antibiotics and reduce selection pressure that drives resistance. Moreover, we must all think long and hard about who we actually are when it comes to antimicrobial resistance. In doing so we must all work just as hard to ensure fair access to antibiotics as we do to tackling excess.

Ramon

 

 

[1] Declaration of Interest: Professor Shaban was the project leader of a research consortium at Griffith University contracted by Australian Commission on Safety and Quality in Health Care to contribute to this report. No other interests to declare.

[2] Das P & Horton R. (2015) Antibiotics: achieving the balance between access and excess. The Lancet, Vol 387, Issue 10014, p102-104.