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12/10/2017 | Title of the presentation 1
The 2017 WHO EML AB chapter
(6th June 2017)
WHO HQ, Geneva 11 October 2017
Nicola Magrini
Secretary, WHO Expert Committee on the Selection and Use of Essential Medicines,
Essential Medicines Department, WHO
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The 40 years of EML (1977 – 2017)
1977 1st Model list published, approx. 200 active substances
List revised every two years by WHO Expert Committee
2002 Revised procedures approved by WHO
The first list was a major breakthrough in the history of medicine,
pharmacy and public health
Médecins sans Frontières, 2000
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First EML: 1977 36 pages, 20 references
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Essential Medicines List: Concept and Procedures 4 |
EML & EMLc 2015 - 2017
2015 EML: 409 medicines
– 5th EMLc (children): 294 medicines
20th EML: 433 medicines
– 6th EMLc (children): 314 medicines
586 pages, 1082 references
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12/10/2017 | Title of the presentation 5
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12/10/2017 6
The 2017 AB update and A-Wa-Re Index
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WHO EML: why is it 'model'
• Model for process of selection
• Model list
• Model to facilitate efforts to 'improve health' of population Procurement and Supply
Regulation
Quality
Rational/responsible/optimal Use
Availability Affordability Access Equity
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The 2017 AB update and A-Wa-Re Index
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EML AB 2017: syndromes considered
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EML 2017 applications: example/template
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EML 2017: final template
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EML ACCESS Group
• First and second choice AB for the 23 relevant/frequent syndromes
considered make the ACCESS Group (29 AB)
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EML 2017 AB listing
ACCESS Group
each AB: by indication
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EML AB (not just) listing: ACCESS
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EML AB (not just) listing: ACCESS
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EML AB (not just) listing: ACCESS
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EML WATCH Group
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CIA List: Critically Important Antimicrobials
First developed in 2005, last revision 5th 2016
Intended to help preserve the effectiveness of
antimicrobials
Reference to help formulate and prioritize risk
assessment and risk management strategies for
containing resistance coming from the food chain
(non-human use)
http://www.who.int/foodborne_disease/resistance/cia/en/
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Antimicrobial agents are ranked as
Critically important
Highly important
Important
Highest priority agents
Fluoroquinolones
3rd and 4th generation cephalosporins
Macrolides
Glycopeptides
Polymyxin (colistin)
Recommends not to use in animals or plants classes not currently used in food
producing animals (such as carbapenems) & new classes developed for humans
Ranking of Antimicrobials
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EML AB (not just simple) listing: ACCESS & WATCH GROUP
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AB RESERVE Group: implications for policies
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12/10/2017 | Title of the presentation 24
Mike Sharland,
personal
communication
Penta-id.org
EML A-WA-RE index uses in DU PPS in >20.000 patients
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The ABC of implementation
Implementation:
Dissemination
Adoption
Education
Change
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WHO EML AB: A-WA-RE implications
• AB progressive change of status (AB are different, the more you use, the more
you lose them)
• The great potential: OneHealth common goals in human health, agriculture and
food producing animals
• The difficult (long-term) part: implementing optimal uses
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Back to basics on implementation
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Where am I?
You’re 30 metres above the ground
in a balloon
You must be a researcher
Yes. How did you know?
Because what you told me is absolutely
correct but completely useless
You must be a policy maker
Yes, how did you know?
Because you don’t know where you are, you don’t know where you’re going, and now you’re blaming
me
J Lomas, 2007
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We need to look to non-traditional stewards, such as community
health workers and members of the public, in settings where health-
care professionals are a scarce resource.
Goff and Mendelson, Lancet ID, 2017
12/10/2017 | Title of the presentation 30
Global implementation/stewardship
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Effect size: moderate though higher than average Quality Improvement studies
February 2017
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12/10/2017 | Title of the presentation 32
Contents of the presentation
• The 2017 WHO EML AB chapter (6th June 2017)
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The Expert Committee recommended the appointment of a standing EML working group to:
• consider reviewing additional clinical syndromes
• adapt the current clinical synopsis to produce short structured documents;
• coordinate the development for the EML and EMLc of a guidance document on
optimal dose and duration of antibiotic;
• review the differential effect of antibiotic classes on the selection of resistance;
• Define key stewardship messages associated with the new categorization and
develop more detailed guidance to assist with the implementation of
recommendations
12/10/2017 | Title of the presentation 33
EML 2017-2019: a standing AB WG
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Public Awareness
Campaigns: - Key messages
- Privilege contents
based on evidence
3 Priority Pathogens List
- R&D
6
Research Priorities &
GARDP new AB
7
Essential Diagnostics 8
Drug Utilization
- Hospital pps
- Community use
- Across sectors
(animals and
agricolture)
9
Animals & Agriculture
One Health
- CIA List (EML bridges)
10
Stewardship &
Education & audit
WHO package based
on new EML and 21
syndromes guidances
4
Implementation: context dependent and
research oriented
Health System
programs: monitoring
5
EML AB listing (3+) 1
Syndromes guidances
Comprehensive
Review of optimal use
2
5 Paediatric
Syndromes and STI
indications
New EML website: - database., new
format
- New App?
EML AB
strategy
2017
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12/10/2017 35