As part of the “Action to support implementation of Codex AMR Texts (ACT)” project, six countries have finished assessing their antimicrobial resistance (AMR) situation, in particular the status of implementation of measures to minimize and contain foodborne AMR. This was part of capacity building activities to manage the development and transmission of foodborne AMR through the adoption and implementation of relevant Codex standards. To learn more about this process and the expected impact, we talked to Jorge Pinto Ferreira, FAO Food Safety Officer (pictured left).  Ferreira is a veterinarian, with an extensive background in Food Safety, Public Policy, Population Medicine, and Public Health, and 15 years’ experience working in the area of AMR.

Where did your work with AMR begin?
I started my professional career as a dairy cow clinician, having faced first-hand multiple cases of antimicrobial resistance. Afterwards, I had positions in research and a consultancy and at the World Organisation for Animal Health in Paris before moving to FAO. This educational and professional background allows me to have a good understanding of the different perspectives that stakeholders have regarding AMR, and therefore to moderate the assessment exercises.

You traveled to Bolivia, Cambodia, Colombia, Nepal, and Pakistan, and also supported Mongolia online to assess their progress.
The main goal was to assess how each country was and is doing regarding the implementation of Codex AMR texts (Guidelines for Risk Analysis of Foodborne Antimicrobial Resistance, Guidelines on Integrated Monitoring and Surveillance of Foodborne Antimicrobial Resistance, and Code of Practice to Minimize and Control Foodborne Antimicrobial Resistance). I was one of the facilitators to discuss the assessments at the meetings. Besides this, these missions were important to either start or solidify the professional relationships with the project country and regional staff, and with the key stakeholders in each country. 

Why was it important for countries to do this exercise?
It is important to identify the gaps in country infrastructure and efforts to minimize and contain foodborne AMR, and with those in mind, to prepare the action plan and road map that will help the country to bridge those gaps. One should never lose sight of the overall picture: by implementing Codex texts, countries are assuring food safety for their citizens, and ensuring fair practices in food trade. These exercises were important as a key step not only in identifying the gaps but also facilitating multi-stakeholder communication and coordination. This is critical when addressing AMR.

In this process, five countries used the FAO AMR Progressive Management Pathway (PMP) tool while Nepal used the Codex Code of Practice (COP) tool, could you please tell us about these tools and how they helped the countries? What is the difference between those two tools?
The tools should not be compared, because they were developed for different purposes. The PMP targets two aspects: first, an assessment of the country’s AMR National Action Plan (NAP), and second, an evaluation of the level of implementation of the NAP. On the other hand, the Codex COP tool assesses the country’s level of implementation of the Codex Code of Practice to Minimize and Control Foodborne Antimicrobial Resistance. So, while there is some overlap between the scope of the two tools, the Codex COP tool is more targeted. With the difference in scope, the time needed to implement both tools also varies. While a preparatory phase is needed in both cases, the PMP is usually implemented in a meeting with relevant stakeholders and experts over three days. The COP tool, with its more focussed goal, can be implemented during a one-day meeting with the right experts and stakeholders. Ultimately the aim of both tools is to determine a clear set of actions that can move the country forward in its efforts to address foodborne AMR.

What were the biggest challenges in this assessment process?
The assessment validity tends to be as high as the commitment of the country's stakeholders. Due to the cross-cutting nature of AMR, this covers a broad range of interested parties. So, the mapping of the stakeholders can sometimes be challenging. The assessment process went smoothly, and now it is time for all of us to work to ensure implementation of the agreed decisions and action plans.

What are the results and lessons learned so far?
An important result was a detailed assessment of each country’s situation regarding AMR/ antimicrobial use (AMU), and in particular on the status of implementation of the Codex AMR Code of Practice. One of the beauties of this project is that each country’s situation is different from the others, which drives us to develop tools, training and activities to support a range of different scenarios and contexts. Nevertheless, I would say that there were a couple of topics that seem to be common for most countries.

For example, the need to increase awareness of AMR and AMU among all concerned stakeholders. In addition training for animal producers, focusing, for example on biosecurity or good husbandry practices, and both terrestrial and aquatic animals. There are gaps in surveillance of AMR microbes, namely in environment, and the production of plants/crops.  There are still some hurdles to overcome when it comes to stopping the use of growth promoters in the animal production sector. We see a lack of capacity to implement prescription requirements to access antimicrobials although the implementation of a prescription requirement to acquire an antimicrobial does not seem realistic at this point.

What was the biggest inspiration for you in guiding the countries?
My daughter and my dog. Why? Because by addressing foodborne AMR we, as a project team, and also each country stakeholder, directly and indirectly contributing to assuring global health security or doing our best to make sure that future generations will have access to a healthy life, and safe and nutritious food. By working on the ACT project, we are contributing to the healthy life of those that we love. Those of us who have the pleasure and the privilege of working on global health, global food safety, and food security, no matter if at the country, regional or global levels, should always keep in mind that it is not just about us, but also about the others, the food producers or processers among others working every day to produce the food we eat. We should encourage a common mindset of working for the common good.

What is next after the assessments? How are the countries doing?
Each mission ended with a clear output: the assessment itself, plus a detailed list of actions needed, the stakeholders that could take those actions on board, and a rough timeline of when those tasks could be completed. The countries are now defining a more granular road map to move from an aspirational list of actions to a reality of fulfilled gaps. Our colleagues at the national and regional levels support them, and I would like to highlight and appreciate their effective and inspiring work – those are the pivotal pieces that catalyze our action plan.

The ACT project is a five-year project. What do you expect will change and how will you measure the effectiveness of the ACT project?
Before addressing directly this question, let me take this opportunity to thank the Republic of Korea for funding this project. As a global community, we can only be very thankful when any country is willing to support others’ development and capacity building.

By the end of the project, I am quite confident that the major gaps that we identified in the assessment exercises will be filled in. This means, that each country will have a higher level of implementation of what is stated both in the Guidelines on Integrated Monitoring and Surveillance of foodborne Antimicrobial Resistance and the Code of Practice to Minimize and Control Foodborne Antimicrobial Resistance. At the same time, we need to have a realistic perspective: achieving 100 percent implementation of both documents in the six countries is not doable, but it is feasible for the countries to implement parts of the Code of Practice and Guidelines that will enable them to improve their management of foodborne AMR.  

To measure the effectiveness of the ACT project, we can repeat the assessment exercises that we just completed.  I would however keep in mind two critical points: first, countries are struggling with assessment fatigue, and second, it will take years/decades until some of the measures taken now will be translated into an effective change in the “field” reality, and this has to do with the biological complexity of AMR. AMR is a multifaceted phenomenon, and it is the sum of multiple actions, from an individual to a country, that will lead to an improvement in the alarming current global situation.

In general, why do you think we need the ACT project to address the foodborne AMR issues?
We often measure the significance of a global health issue by its impact in terms of human health. And AMR is, unfortunately, in the top five of this ranking, meaning millions of human deaths per year at a global level. In reality, the impact of AMR is much broader, and this becomes quite obvious when we look at the Sustainable Development Goals, and how many of them are linked to having effective antimicrobials.

The ACT project addresses foodborne AMR. At this point, the exact quantification of the significance of foodborne AMR is unknown. But clearly, it is a part of the puzzle that needs to be addressed.  We are all consumers of food so if the food is contaminated with antimicrobial resistant organisms we are exposed.  By controlling it, we are working towards a healthy future for the next generations, and this can only motivate all of us, as a global common goal.

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