Global Hygiene Council response. Consultation on a draft Global action plan to address antimicrobial resistance

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1 Global Hygiene Council response Consultation on a draft Global action plan to address antimicrobial resistance The questionnaire is divided into four sections. The questions are broadly framed and intended to give you the opportunity to enter into some depth and explain your organization's viewpoint. While only questions marked with * are mandatory, we would appreciate answers to as many as possible. Where a choice of answer needs to be selected please highlight your answer. Before answering the questions, please refer to our list of supporting documents. About you 1. Name of individual respondent* Professor John Oxford 2. address* (preference for official addresses) hygienecouncil@toniclc.com 3. Are you authorised to represent your organization or interest group?* Yes 4. Organization Name* Global Hygiene Council 5. Address of the organization* Tonic Life Communications, 10 Dean Farrar Street, London, SW1H 0DX 6. Organization website (if available) 7. Country* United Kingdom (with members from Australia, Brazil, China, France, Germany, India, Indonesia, Italy, Japan, Malaysia, Nigeria, South Africa, Saudi Arabia, Thailand, UK and USA) 8. Type of Organization* Government department, ministry or agency Development or aid agency, foundation, trust or other funding authority International developmental organization 1

2 Academic institution Civil society Private sector Other non-governmental organization (NGO) Other (please specify) The Global Hygiene Council is a group of the world s leading global experts in the field of microbiology, virology, infectious diseases, immunology, and public health who have come together to formulate realistic and practical recommendations on simple hygiene measures to help the public improve levels of hygiene in the home and community and, in turn, help to prevent the spread of all kinds of infections. The Council is funded by an unrestricted educational grant from RB. 9. Main sector of interest Human health - Yes Animal health Finance/economics Agriculture or food Environment Communication, education and community - Yes Other (please specify) 10. Would you like to be added to our mailing list to receive updates on the development of the global action plan?* Yes 2

3 General questions 1. From the perspective of your organization, what are the most important areas of concern in AMR? The Global Hygiene Council believes that the following are the most important areas of concern in AMR: 1. Prevention of infection and transmission of infectious diseases is key to combating AMR. Targeted hygiene, such as regular handwashing with soap and clean water and surface disinfection, will not only kill pathogenic microorganisms but will also reduce the likelihood of individuals becoming infected with potentially antibiotic-resistant microbes. Fewer infections will lead to an overall reduction in prescriptions for antibiotics. 2. Communication to the public via the media during an infectious disease outbreak to raise awareness of the importance of hygiene measures in helping to prevent transmission and break the chain of infection, to ultimately reduce the number of antibiotic prescriptions. Please note, the Global Hygiene Council believes hygiene messages should be communicated to the public throughout the year. However, during an infectious disease outbreak it is important to communicate the need for heightened hygiene precautions. 3. The media misunderstanding and misinterpretation of the Hygiene Hypothesis and the Old Friends Hypothesis. The Global Hygiene Council has reviewed the available literature for the widely held Hygiene Hypothesis, which claims that excessive hygiene practices lead to an increased incidence of autoimmune and atopic diseases, such as asthma and eczema, and has concluded that there is no supporting scientific evidence. A focus on the Hygiene Hypothesis in recent years by the global media has resulted in sensationalised news headlines, for example How keeping children too clean can wreck their immune systems (Daily Mail, 2012) and Over-hygienic parents could be cause of diabetes (Euronews, 2012). Such articles misinterpret the scientific evidence and may prevent the adoption of good hygiene practices, leaving members of the public vulnerable to infection by pathogens, including antibiotic-resistant microbes, which can lead to serious illness and transmission of self-limiting infections, which may drive a patient desire for antibiotics. A new theory that has the potential to replace the Hygiene Hypothesis as a central branch of Darwinian medicine, is the Old Friends Hypothesis. This theory claims that humans have lost touch with a variety of microorganisms that we coevolved with and which played a key role in the development of our immune systems. The loss of exposure to these old friends is due to changing lifestyle, diet and stress, and not as a result of personal and home hygiene. Lack of contact with these Old Friend microbes, and not with illness-causing pathogens, is linked to increased levels of autoimmune and atopic diseases. Advocates of the Old Friends Hypothesis, including the Global Hygiene Council, warn that relaxing hygiene standards is not the right way to boost exposure to immunomodulatory microbes and this would leave individuals vulnerable to infection by pathogens, including antibiotic-resistant microbes. In 3

4 addition, the overuse of antibiotics to treat infections that could be prevented by hygiene will negatively impact the human gut microbiome, which is critical for the development of the immune system. The Global Hygiene Council believes it is critical to provide the media with the collateral to accurately interpret the Old Friends Hypothesis. In doing so, the essential role of hygiene in killing pathogens and preventing infection by potentially antibiotic-resistant microbes will be highlighted and communicated by the media to consumers and healthcare professionals. 4. Communication to and education of the public via the media of the difference between viruses and bacteria, and that antibiotics are ineffectual against viruses. It is hoped this will help to decrease the number of unnecessary prescriptions of antibiotics for viral infections, such as the common cold, influenza and gastrointestinal illnesses, ultimately leading to a decrease in AMR. 2. Is your organization currently involved in work related to AMR? No If Yes, how? N/A 4

5 Questions about the draft global action plan outline document Before the WHA resolution was adopted, two WHO AMR Strategic Technical Advisory Group (STAG) meetings were held in anticipation, which included members plus a large number of representatives from other organizations. These meetings identified key issues, concerns and led to the development of a draft outline. As this consultation progresses and stakeholder meetings are held, the secretariat will harvest and incorporate the input into the draft global action plan. 1. How would you rate your understanding of WHO s intention in the development of a global action plan to address AMR? Very good Good_X_ Fair Poor Additional comments 2. From the perspective of your organization, are the major issues relating to AMR outlined in the draft global action plan? Y N _ X _ If No, what additional issues need to be addressed? The Global Hygiene Council believes that the following three issues need to be addressed as part of any national or international initiative to combat AMR: 1. Communication to and education of the public via the media of the difference between viruses and bacteria, and when to use antibiotics, ultimately leading to a decrease in unnecessary prescriptions. 2. The media misunderstanding of the Old Friends Hypothesis and the Hygiene Hypothesis may prevent the adoption of good hygiene practices, leaving members of the public vulnerable to infection by pathogens, including antibiotic-resistant microbes, which can lead to serious illness. (Please see response to question 1 in the General questions section for more detail.) 3. The need for targeted surface and personal hygiene to remove and kill potentially harmful microorganisms, including antibiotic-resistant microbes, from areas in the home, such as hand-contact surfaces (kitchen worktops, taps/faucets, kitchen sponges/cloths, toilet flush handles and door handles) that have been identified in Global Hygiene Council studies as hygiene hotspots. 1 In addition, increased hygiene measures should be practised in high footfall public places, such as when on public transport and in a doctor s surgery or hospital where the risk of cross-infection is heightened. Please note, there is a perception that the use of antimicrobial/antibacterial surface cleansers contribute to the problem of AMR and hence there is a need to 5

6 communicate to the public that this is not the case when products are used at concentrations as directed, as evidenced in previous studies,2,3,4,5 6

7 Questions on the Building blocks described in the draft outline You will notice, the global action plan has been constructed around building blocks in recognition that different countries will have different starting points. In this situation, countries can choose building blocks to concentrate upon. Each building block specified has been identified as a key area where specific attention, planning and work are needed to achieve progress in addressing AMR. Through questions in this section, we would like to hear your opinions on these building blocks in more detail. II. Building block-2: Identifying the most important approaches for preventing development of infections and the steps needed to move beyond guidance to more effective implementation of such approaches a) What do you consider to be the main issues under this priority? The Global Hygiene Council believes that the underlying issues that need to be addressed in order to prevent the development of infections, including those caused by antibiotic-resistant microbes, relate to community responsibility and the understanding that AMR has the potential to develop outside of healthcare settings, including in the home. 1. It is the responsibility of all members of the community to help combat AMR. In healthcare settings it is crucial to reinforce to HCP s the need to responsibly prescribe antibiotics to ultimately prevent AMR from developing. In addition, HCP s must practice effective hygiene measures (e.g. regular handwashing) when treating patients to prevent the transmission of infections, including those caused by antibiotic-resistant microbes, to vulnerable individuals. In the community members of the public need to be reminded that they must complete the courses of antibiotics they are prescribed to help prevent AMR from developing. In addition, they need to be educated on the importance of targeted hygiene in preventing the transmission of pathogens, including potentially antibioticresistant microbes, in the community, the home and also into and out of healthcare settings when attending appointments or visiting friends/relatives. 2. Cross contamination in the home has the potential to enable the widespread transmission of infectious diseases, including those caused by antibiotic-resistant microbes. A global study conducted by the Global Hygiene Council in 2014, the Hygiene Home Truths Survey, 6 found that 83% of those respondents surveyed think their home poses no or a low risk to them in terms of picking up infections. However, the Global Hygiene Council knows from our previous Bacterial Survival 7 and Influenza Survival 8 studies that pathogenic microorganisms can survive on household surfaces for prolonged periods, and for up to 48 hours in the case of S. aureus and the Influenza virus. These studies highlight the need to communicate to members of the public how, by implementing simple and targeted hygiene measures, they play a central role in helping to 7

8 prevent the transmission of infections, including those caused by antibiotic-resistant microbes, within the home but also into the wider community and healthcare settings. b) What are the main actions that need to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? The Global Hygiene Council believes that the following actions need to be taken by the below actors/stakeholders: Actions: 1. Education of members of the public and the media about the importance of targeted and effective hygiene practices to ensure limited exposure to pathogens that can cause serious illness, including antibiotic-resistant microbes, and to break the chain of infection. The communication of these messages should also be aimed at counter-acting the Hygiene Hypothesis to encourage informed and responsible reporting by journalists. The Global Hygiene Council advocates regular handwashing with soap and clean water at keys times to help break the chain of infection. Such key times include before and after handling raw food; before eating; after using the toilet; and before and after administering any medication or first aid or touching someone who is particularly vulnerable to infections, e.g. someone who is unwell in hospital. In line with the Centers for Disease Control and Prevention (CDC) and the Global Handwashing Day Initiative, the Global Hygiene Council recommends members of the public spend at least 20 seconds rubbing their hands with soap, paying particular attention to the backs of the hands, under the finger nails and between the fingers. 2. Incorporation of hygiene messages into AMR materials and messaging, in terms of positioning targeted hygiene measures as a means of preventing infection by antibioticresistant microbes that currently have limited treatment options due to the inefficacy of antibiotics, thus helping to combat AMR and protecting the efficacy of antibiotics. 3. Inclusion of the following hygiene messages in communications aimed at the public and healthcare professionals during infectious disease outbreaks and times of increased risk of infectious disease spread e.g. during the cold and flu season: Targeted hygiene measures are a preventative measure against infection and the transmission of infectious diseases. Targeted hygiene measures can help to decrease the number of antibiotic prescriptions by breaking the chain of infection. Targeted hygiene can be used to help prevent the spread of viral infections, which are often inappropriately treated with antibiotics despite the fact antibiotics are ineffective against viruses. 8

9 Ultimately targeted hygiene can help to decrease the rate of AMR. Actors/stakeholders: 1. Government Providing both national policy and a joint international approach to combating AMR in healthcare settings, which highlights the important role hygiene plays. In addition, implementing/endorsing national and/or international public hygiene awareness campaigns and initiatives e.g. Global Handwashing Day. 2. Educators Educating both members of the public via school and higher education, and HCP s via ongoing professional training about the threat AMR poses to health and the important role hygiene plays in combating it. 3. Healthcare professionals In addition to responsible prescribing of antibiotics, practicing good hygiene measures when treating patients and recommending increased hygiene to patients as a means of preventing the transmission of infections to others and preventing future infections. 4. Media Responsible and informed reporting of the Old Friends Hypothesis based on the scientific evidence available and inclusion of hygiene messages when discussing infectious disease outbreaks and AMR. 5. Hygiene-related brands In addition to supporting the work of governments, and national and international health authorities, investing in large-scale communication campaigns beyond their normal brand activity to help drive awareness of the importance of hygiene in combating AMR. This could be in terms of using media, advertising and marketing tactics to target their existing customers, but also to reach a wider audience, as we aim to do with the Global Hygiene Council s activities. 6. Members of the public In addition to adhering to advice from HCP s on completing courses of antibiotics, practicing good hygiene measures in the home and community to help protect themselves and others from infection by potentially antibiotic-resistant microbes. 9

10 c) What significant work has already been done to address this? (please provide references where possible) The Global Hygiene Council commends the WHO, CDC and other partners on their 2014 AMR campaign SAVE LIVES: Clean Your Hands aimed at HCP s. We believe a campaign of this scale and prominence is now needed to urge members of the public of the importance of practising good hand hygiene in the community as a means of combating AMR. The Global Hygiene Council would be willing to support and endorse such a campaign as appropriate. The Global Hygiene Council itself has conducted a number of media activities and global studies that aim to raise public awareness and highlight the importance of good hygiene practices in the home and community to help prevent the transmission of infections and ultimately help combat AMR. To date the Global Hygiene Council s activities have reached in excess of 2 billion people worldwide via the media. 1. Members of the Global Hygiene Council from countries, including Australia and India have previously presented to consumer-facing media on the topic of antibiotic resistance, including the causes, threat posed and solutions, such as targeted hygiene measures. The members will continue to communicate such messages to the public as able. 2. Home swabbing studies 1 conducted by the Global Hygiene Council in 2009, 2010 and 2014 analysed the levels of pathogenic bacteria (Enterobacteriaceae, E. coli, Pseudomonas spp. and Staphylococcus aureus) present on a range of household items / surfaces in 100 typical family homes from across the world. The reports were accompanied by a series of public-facing media materials, which were used globally in media outreach to generate mass public awareness of the fact that the home is not a safe haven from infections that can cause illness. Please note, the 2009 swabbing study was published in the Journal of Infection Prevention in July Bacterial Survival Study: Longevity of Survival Study 7 conducted by the Global Hygiene Council in 2011 tested the survival of a range of pathogenic bacteria (Campylobacter jejuni, E. coli, Listeria monocytogenes, Salmonella and S. aureus) across different household surfaces and environments. The report was accompanied by a series of public-facing media materials, which were used globally in media outreach to generate mass public awareness of the ability of some pathogenic microorganisms to survive on household surfaces for up to 2 days, and the importance of targeted hygiene measures in preventing transmission and crosscontamination within the home. 4. A MRSA in the home pilot study, conducted by Simmons College, Boston, Massachusetts and funded by RB, investigated the presence and sources of S. aureus, including methicillinresistant S. aureus (MRSA) in the home environment. 10

11 The study demonstrated the presence of MRSA at hand-contact surfaces in healthy homes without reported infections or carriage. A positive correlation was found between the isolation of MRSA from surfaces and the presence of a cat in the home. The study author concluded the results provide further evidence for the potential for infection transmission, in this case antibiotic-resistant microbes, through inanimate surfaces and underscores the need for good hygiene practice in the home. 10 d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) The Global Hygiene Council believes that the following five measurables would be indicators of progress (nationally and globally): 1. A decrease in the number of cases and fatalities from infectious diseases. 2. A decrease in the number of prescriptions for antibiotics for self-limiting infections. 3. A decrease in the number of cases of hospital-acquired infections and resistant strains. 4. A decrease in the number of AMR isolates present. 5. Improved media perception and increased HCP and public awareness of the need for better hygiene practices to help combat AMR. References 1 Global Hygiene Council. Hygiene home truths swabbing study Data on file.* 2 Lear JC et al. Chloroxylenol- and triclosan- tolerant bacteria from industrial sources. Journal of Industrial Microbiology and Biotechnology. 2002; 29: Marshall BM et al. The frequency of antibiotic-resistant bacteria in homes differing in their use of surface antibacterial agents. Current Microbiology. 2012; 65: Cole EC et al. Investigation of antibiotic and antibacterial agent cross-resistance in target bacteria from homes of antibacterial product users and nonusers. Journal of Applied Microbiology. 2003; 95: Rutala WA et al. Susceptibility of antibiotic-susceptible and antibiotic-resistant hospital bacteria to disinfectants. Infection Control and Hospital Epidemiology. 1997; 18(6): Global Hygiene Council. Hygiene home truths survey Data on file.* 7 Global Hygiene Council. Bacterial survival study: Longevity of survival Data on file.* 8 Global Hygiene Council. Degradation of Influenza H1N1sw on 4 different household surfaces Data on file.* 9 Oxford J et al. An international survey of bacterial contamination and householders knowledge, attitudes and perceptions of hygiene. Journal of Infection Prevention. 2013; 14(4): * 10 Scott E et al. A pilot study to isolate Staphylococcus aureus and methicillin-resistant S aureus from environmental surfaces in the home. American Journal of Infection Control. 2008; 36(6): * *Please note these references can be found in the annexe. 11