This Congressional briefing document discusses the growing crisis of antibiotic resistance and its enormous economic and public health impacts. It notes that antibiotic resistant infections result in more deaths and disability and cost the healthcare system billions annually in increased costs and lost productivity. The overuse of antibiotics in agriculture also contributes to the rise of resistant bacteria, with millions of pounds used annually in food animals often just for growth promotion rather than therapeutic purposes. Presenters recommend banning the non-therapeutic use of antibiotics in food animal production, increasing veterinary oversight of antibiotic use, and improving monitoring and surveillance of antibiotic resistance in both the healthcare and agricultural sectors.

1. Congressional Briefing Antibiotic Resistance: A Multi-Billion Dollar Healthcare Crisis

2. Congressional Briefing Antibiotic Resistance: A Multi-Billion Dollar Healthcare Crisis The cost of losing antibiotic effectiveness RamananLaxminarayan Center for Disease Dynamics, Economics & Policy (CDDEP) Resources for the Future

8. Burden of resistance: Lower quality of care Resistant infections result in more deaths and disability

9. Odds of dying of MRSA are nearly twice as large as for sensitive Staph

10. Burden of resistance: Lower quality of care The estimated number of people developing a serious MRSA infection (i.e., invasive) in 2005 was about 94,360 (CDC) Approximately 18,650 persons died during a hospital stay related to serious MRSA infections (CDC)

11. Burden of resistance: Higher cost of care Methicillin resistance was associated with an increase in length of hospital stay (increased 1.29 fold) and hospital charges (increased 1.36 fold) after the bacteremia (Cosgrove 2005)

12. Resistance is leading to the use of more powerful antibiotics…

13. …that are also more costly.

14. Overall societal costs Between $378 million to $18.6 billion annual cost of increased resistance in community-acquired infections (Elbasha 2001) $30 billion a year (Institute of Medicine)

15. Difficulty in measuring burden No DRG for resistance-related hospitalization Correlation between disease severity and colonization with resistant pathogen Not all antibiotic use is bad

16. Who bears the cost?

17. Where do resistant bacteria come from? Antibiotic use in healthcare Poor infection control Older, sicker patients undergoing more complex procedures Antibiotic use in animals

18. Congressional Briefing Antibiotic Resistance: A Multi-Billion Dollar Healthcare Crisis Dr. Lance Price Director, Center for Metagenomics and Human Health, Translational Genomics Research Institute

19. Key Concepts Bacteria become resistant to antibiotics People become infected with antibiotic resistant bacteria

20. Antibiotic RIP Antibiotic Selection

21. Anytime you use antibiotics you are potentially selecting for antibiotic resistant bacteria

22. Antibiotic use in food-animal production Single greatest use of antibiotics Millions of pounds every year Most of the antibiotics are classes important to human medicine Selects for cross-resistant bacterial populations Most antibiotics are fed to animals in the absence of disease!

24. If an animal production system requires routine antibiotic inputs to keep the animals from becoming sick, then that system is broken!

25. Antibiotic

28. Johnson 2007

29. Antibiotic

30. What happens if you remove the antibiotics from food animal production? Preservation of Antibiotics for Medical Treatment Act (PAMTA)H.R. 1549/S. 619

32. We must eliminate non-therapeutic and routine antibiotic use in food animal production in order to preserve the utility of our life-saving antibiotics for treating sick people! PAMTAH.R. 1549/S. 619

33. Congressional Briefing Antibiotic Resistance: A Multi-Billion Dollar Healthcare Crisis Combating Antimicrobial Resistance: Veterinary Medicine’s Role Michael J. Blackwell, DVM, MPH

34. The Broadest Medical Profession: Veterinary Medicine Three medical professions Physicians, Dentists, and Veterinarians Only veterinarians have comparative medicine training, making it the broadest Multiple species (including those in the food supply) Broadest prescription authority Ensures public health by addressing diseases in animals before they affect humans Food-borne disease agents affecting humans, that are also found in animals include, Salmonella, and E. coli Infectious diseases in humans that originated in animals include, HIV/AIDS, SARS, West Nile Virus, Avian Influenza, and ?Swine Influenza?

35. Uses of Antimicrobials in Food Animals (i.e., food supply) Therapeutic (treatment) Diagnosed microbial disease Prophylactic (prevention) After an exposure, but before clinical onset In advance of expected exposure

36. Uses of Antimicrobials in Food Animals (i.e., food supply) Non-therapeutic (routine) Absence of disease, or exposure, or expected exposure (i.e., healthy animals) Weight gain, growth promotion, feed efficiency Many drugs are available directly to lay persons veterinary oversight not required

37. To Reduce Antimicrobial Resistance Stop non-therapeutic (routine) uses Require veterinary oversight of all uses of antimicrobials in animals, especially if the drug is used in human medicine Veterinarians are the best trained and the only ones licensed to decide appropriate uses

38. To Reduce Antimicrobial Resistance Use options other than antimicrobials as a first line of defense More focus on husbandry practices waste management, less crowding, better ventilation Improve surveillance, monitoring, and reporting Better drug use data Risk Assessments More public funding of resistance research Less bias and less of a conflict of interest

39. Thank You!

40. Congressional Briefing Antibiotic Resistance: A Multi-Billion Dollar Healthcare Crisis Pew Commission on Industrial Farm Animal Production Bob Martin

41. Commission Membership 16 Commissioners from diverse background Animal agriculture producers, human medicine, public health, animal health, ethics, religion, state and federal policy represented Academic contributors from major universities

42. Charge to Commission Commission charged with developing solutions to the public health, environmental, rural community, and animal welfare problems caused by industrial animal feeding operations Commission found, generally, industrial animal operations presented an unacceptable threat to the public health, damage to the environment and rural communities and was harmful to the animals

43. Commission Process 11 meetings held in all regions of the United States, including two public hearings 250 hours of deliberations, including more than 50 hours with animal ag representatives 8 technical reports, thousands of pages of stakeholder comments, Commissioner expertise, staff papers informed the Commission Thousands of pages of information, including 170 peer reviewed reports

44. Recommendations Commission recommendations adopted by consensus 24 primary recommendations dealing with public health, animal welfare, the environment, and rural communities. 12 of those concerned public health Five of those focused on antibiotic use in industrial animal agriculture

45. Antimicrobial Resistance Recommendations Phase out and ban non-therapeutic use of antibiotics in food animal production Ban new approvals of non-therapeutic use of antibiotics for food animals and retroactively investigate previously approved antimicrobials Strengthen Guidance #152 Commission defines therapeutic as the use of antimicrobials with a diagnosed microbial disease

46. Antimicrobial Recommendations (continued) Non-therapeutic use is defined as use in the absence of microbial disease or known microbial disease exposure, such as for growth promotion, weight gain, or routine disease prevention Prophylactic use is defined as use in a healthy animal in advance of expected exposure or after an exposure but before onset of confirmed clinical disease

47. Antimicrobial recommendations (continued) Improve monitoring and reporting of antimicrobial use in food animal production Improve monitoring and surveillance of antimicrobial resistance in the food supply, the environment, and animal and human populations Increase veterinary oversight of all antimicrobial use in food animal production to prevent overuse and misuse

48. Public Health Recommendations Implement a disease monitoring program and a fully integrated and robust national database for food animals to allow 48 hour trace back Increase monitoring of possible public health effects of CAFOs on people who live and work in or near facilities Fully enforce current state and federal regulations and legislation

49. Strengthen relationships between physicians, veterinarians, and public health professionals to deal with CAFO public health risks Create a Food Safety Administration combining food inspection and safety responsibilities of USDA, FDA, and EPA Develop a flexible, risk-based food safety system from farm to fork More aggressive mitigation of production diseases Public Health Recommendations(continued)

50. Environmental Recommendations Improve enforcement of existing federal, state, and local regulations to improve the siting of facilities and to protect the health of those living near them Develop new system to deal with farm waste Increase and improve monitoring and research of farm waste to hasten new treatment methods

51. Environmental Recommendations(continued) Increase funding for research to improve waste handling systems and to standardize measurements for better comparison between systems

52. Animal Welfare Recommendations Implement federal performance-based standards to improve animal health and well-being Implement better animal husbandry practices Phase out most restrictive confinement systems within 10 years Improve animal welfare practices and conditions Improve animal welfare research

53. Rural Community Recommendations States, counties, and local governments should implement zoning and siting guidance for new facilities that fairly and effectively evaluate the suitability of a site Implement policies to promote a competitive marketplace

54. Additional Research Recommendation Expand public funding for, and reform, animal agriculture research

55. Congressional Briefing Antibiotic Resistance: A Multi-Billion Dollar Healthcare Crisis