Corporate report

UKHSA Advisory Board: Antimicrobial resistance

Updated 16 September 2024

Date: 17 September 2024

Sponsor: Susan Hopkins

Presenter: Colin Brown

1. Purpose of the paper

Here we provide an update on UKHSA’s activity against the spread of antimicrobial resistance (AMR). We summarise actions implemented to tackle AMR through the new 5-year National Action Plan (NAP) for AMR (2024 to 2029) published in May 2024. Advisory Board feedback will ensure activities are appropriately ambitious yet achievable, aligning with UKHSA’s 3-year strategy.

2. Recommendations

The Advisory Board is asked to:

• note the activities underway in UKHSA to tackle AMR and the inter- and intra-organisation interdependencies to the delivery of the UKHSA AMR programme in support of the 2024 to 2029 NAP
• comment on and identify any gaps in UKHSA plans for delivery across the organisation and externally and provide feedback on the key challenges for the implementation of the UKHSA AMR programme

3. Background

A first report on UKHSA AMR Programme progress was presented to the Advisory board on 23 September 2023. This paper provides updates on subsequent activity.

4. UKHSA role in NAP development and cross organisational implementation

The UK Government, including all four UK nations, owns the UK AMR 2024 to 2029 NAP. The Department of Health and Social Care (DHSC) provides overall coordination, with UKHSA playing a crucial role in the development and implementation of the plan, including coordinating the development of UK-wide human health targets and leading on key outcomes and commitments, supporting our ability to drive and monitor the impact of public health interventions.

The new human health targets as laid out in the 2024 to 2029 NAP are:

• by 2029, we aim to prevent any increase in a specified set of drug-resistant infections from the financial year (FY) 2019 to 20 baseline
• by 2029, we aim to prevent any increase in Gram-negative bloodstream infections from the FY 2019 to 20 baseline
• by 2029, we aim to reduce total antibiotic use in human populations by 5% from the 2019 baseline
• by 2029, we aim to achieve 70% of total use of antibiotics from the Access category (new UK category) across the healthcare system
• by 2029, we aim to increase UK public and healthcare professionals’ knowledge on AMR by 10%, using 2018 and 2019 baselines, respectively

These targets represent an evolution of those in the 2019 to 2024 NAP; for serious drug-resistant and Gram-negative bloodstream infections, counts will likely increase in the next 5 years based on existing trends and a growing ageing population. Preventing any increase from 2019 baseline constitutes a stretch target for the UK. UKHSA successfully influenced a new UK-wide target on public and professional AMR knowledge and outcomes/commitments to tackle health inequalities in AMR.

Between April and June 2024, UKHSA NAP deliverables have been developed and these are now being implemented by teams across the organisation and with NHSE, the devolved administrations and key partners.

The UKHSA AMR governance structure reflects our cross organisational approach, and the UKHSA AMR Steering Group includes UKHSA Directors or Deputy Directors who work on AMR. In addition, a new UKHSA NAP outcome leads group has been created, with senior colleagues across the organisation guiding the operational delivery of the programme and representing UKHSA at the UK AMR Delivery Board.

To strengthen the cross organisational information sharing and knowledge mobilisation of AMR, the UK AMR Programme Forum has further enhanced its reach and been made inclusive and open to colleagues across UKHSA and is chaired on rotation by Deputy Directors across the organisation.

The AMR Programme team is developing an AMR implementation toolkit for use by all UKHSA teams involved in the NAP, to ensure consistency and shared approach.

5. UKHSA AMR programme workstreams and recent successes

UKHSA leads on the new NAP implementation programme 3, producing robust data, developing, and evaluating interventions, used to inform policy decisions on AMR.

5.1 Genomics transformation, including maximising Whole Genomics Sequencing (WGS) capabilities to track and understand epidemiology associated with resistance

UKHSA provides UKAS accredited clinical services for AMR prediction from analysis of WGS in Mycobacterium tuberculosis, Hepatitis C Virus and Influenza A and B viruses. WGS-based AMR gene detection is included in services for common gastrointestinal disease-causing bacteria, alongside Staphylococcus aureus and HIV. AMR gene detection WGS services are in development for Clostridioides difficile, Group A and B Streptococcus and Gram-negative bacterial opportunistic pathogens. Plans to implement longer read sequencing technology for improved investigation of mobile genetic that spread resistance genes are being progressed.

5.2 Strengthening of surveillance infrastructure and analytical capabilities

We developed innovative analytical tools for large datasets via the Unified Infection Dataset (UID), from 2019 – this work underpinned the proceeding UKHSA analytical infrastructure (EDAP). The UID supports epidemiological outputs, infectious disease surveillance, outbreak response and allied research with rich linked data and has supported recent incident investigations, for example recent Shiga toxin-producing E. coli (STEC) O145 outbreak. UID functionality is being built into EDAP (Enterprise Data Analytics Platform) through collaboration with colleagues from the Data, Analytics and Surveillance group to enhance UKHSA’s future data and analytical capacity. EDAP, the UKHSA dashboard, and genomics transformation are critical to ongoing and planned work to achieve our AMR data related ambitions.

5.3 Advancing epidemiology

To better understand AMR burden, we undertook a point prevalence survey of healthcare-associated infections (HCAI) and antimicrobial use (AMU) in acute care hospitals in England in 2023 (analysis in final stage). Data from these works feed into our models of infection, helping determine levels of risk, economic impact, and infection protection control intervention candidates. A national report is expected to be published by October 2024.

5.4 Research, innovation, and discovery

UKHSA displays outstanding examples of (inter)national research partnerships producing high-value insights on AMR, including co-leading two Health Protection Research Units (HPRUs) which run until 2025, with bids for the next round of HPRUs to run from 2025-2030. Over the past 5 years, UKHSA’s contribution as principal or co-investigators in grants totals over £22.5million.

UKHSA leads work packages within two large European consortia, strengthening collaborations across Europe. Firstly, REVERSE: pREVention and management tools for rEducing antibiotic Resistance in high prevalence SEttings (12 European Partners, €14m) evaluates cost-effectiveness of alternative intervention strategies. Secondly, PrIMAVeRa: Predicting the Impact of Monoclonal Antibodies and Vaccines on AMR (18 partners across 10 European countries, €9million). UKHSA also partner in the One Health European collaboration SEFASI: Selecting Efficient Farm-level AMS Interventions from a one health perspective (5 partners across 3 countries, €1million). We are lead partners within many of the 8 newly funded UKRI AMR Transdisciplinary Networks supporting diverse teams of researchers across disciplines to tackle AMR.

Our Porton AMR network leads on the discovery and development of novel antimicrobials, optimising antibiotic combinations, vaccines, and non-traditional therapies (notably phage and polyclonal antibody therapies), including work delivered through partnerships with Industry, the Open Innovation in AMR platform, and partnering with the new PACE AMR funding consortium. In addition, there is the assessment of innovative and alternative infection, prevention, and control (IPC) measures at UKHSA Porton utilising its full-scale mock hospital ward.

5.5 Behavioural insights

Over the last year, the Behavioural Science and Insights group has worked alongside the UKHSA Primary Care and Interventions Unit to both improve our understanding of barriers and facilitators to uptake of recommended behaviours related to AMR and AMS. Qualitative research has identified gaps in domiciliary care workers in Care Quality Commission registered providers (carers) knowledge of AMR and highlighted opportunities to strengthen carers’ abilities to identify symptoms requiring antibiotics in domiciliary care. Qualitative research also suggests that the implementation of technology, as well as more direct communication between community pharmacists and GPs, would help to improve AMS in primary care.

5.6 One Health AMR approach, interactions humans, animals, food, environment

UKHSA and Deloitte conducted discovery work on a UK-wide one health AMR surveillance system and developed an exemplar environment AMR surveillance system. The third joint One Health AMR report on antibiotic use, antibiotic sales and antibiotic resistance was produced in collaboration with Veterinary Medicines Directorate as lead, released in November 2023. UKHSA will coordinate production of a 4th One Health AMR Report by the close of FY 2025 to 2026.

5.7 Health inequalities in AMR

UKHSA has adopted the CORE20PLUS framework to identify what populations will be prioritised for reporting. This has been applied to work across the division with the aim of understanding the impact of ethnicity, deprivation, regional divergence, and social exclusion along with potential confounders, and identifying effective targeted interventions in AMR.

5.8 Unified metric for AMR

The threat of AMR can be challenging to communicate to the public. UKHSA is leading on the UK-wide development of a single overarching AMR metric, incorporating AMR prevalence found in key pathogens, antibiotic prescribing levels, and resultant age-stratified burden. The aim is to provide both the public and the healthcare system with a single measure for tracking AMR that can effectively inform public health interventions. We have initially developed analytical methods to estimate mortality caused by AMR infections.

5.9 Continued global engagement

UKHSA contributes to international AMR and AMU surveillance through a range of surveillance platforms. We participate in Transatlantic Taskforce on AMR and G7 activities and contribute to cross-government preparations for the end September 2024 UN General Assembly. UKHSA contributes to the Global Research on AMR-Global Burden of Disease, including the recent evaluation of AMR between 1990 and 2021. In collaboration with the World Health Organization (WHO) we have developed an AMR Unit Cost Repository, advancing our ability to estimate the cost AMR - a research priority in the 2024 to 2029 AMR NAP.

6. The future of the UKHSA AMR programme

To tackle AMR, UKHSA will exploit new technologies and strengthen professional surveillance networks across government and (inter)national partners, ensuring work is robustly aligned with UKHSA’s Strategic plan 2023 to 2026. New technologies including rapid diagnostics, use of machine learning, and data visualisation will improve available data, granulation, timelines, and interpretation. This will help drive action be it at national level understanding of epidemiology, or a clinician using optimised prescribing informed by the epidemiology and/or rapid diagnostics. Key foci for the NAP 2024 to 2029 include:

• big data and threat detection
• maximising WGS capabilities to understand and track resistance
• modelling, development and evaluation of population level interventions to drive best investment in innovative solutions
• strengthening IPC
• translating research into tangible policy outputs and public health actions
• embedding tackling health inequalities throughout all our activities

As an emerging theme, we aim to address tackling AMR and climate change in collaboration with the UKHSA Centre for Climate and Health Security.

6.1 UKHSA AMR programme 2024 to 2025

Working with DHSC, NHSE, academia, UK devolved governments, and others to deliver the 2024 to 2029 NAP, UKHSA will drive coordinated efforts nationally and internationally to reduce the burden of AMR via a cross-sectoral One Health approach. Key activities for delivery in this first year, are:

• optimising surveillance, to detect, track, analyse trends and model HCAI, AMRI, fungal infections and outbreaks or incidents; monitor antimicrobial usage (including quality of prescribing) and susceptibility; and facilitate cross-organisational response to mitigate risks to patients and the public
• modelling and economic analysis, to strengthen understanding of the causes of infections and impact of interventions
• consolidating laboratory transformations and adoption of meta data, for outbreak investigation and surveillance – as part of the UKHSA genomics programme we are building structured, automated data structures or systems from bringing genomic, phenotypic data and epidemiology together to make analysis easier and facilitate detection of outbreaks across different sites or regions
• strengthening the research and development pipeline to develop new ways to tackle AMR and improve the evidence base, providing the information needed to drive new, improved interventions, nationally and internationally
• global leadership and strengthening international networks tackling AMR, UKHSA will continue to work closely with international health organisations, for example WHO and individual countries, to strengthen national and global AMR surveillance, guidance, policy, and detection of emerging threats

6.2 The funding for AMR

There is currently no financial mechanism to capture total AMR spend across UKHSA in addition to core allocation via CMA Group of £10.7million for 2024 to 2025. Funding is included within each group’s allocated spend, for example laboratory and sequencing staff, core bioinformaticians, modellers, epidemiologists, surveillance teams, health protection teams, and supported by corporate services. While core activities that are easily costed can be accounted for, disaggregation of AMR activities in virology, tuberculosis, sexually transmitted infections, and other areas are difficult to determine. However, all parts of the organisation have prioritised activities in this area and joint business planning is facilitated by the UKHSA AMR internal programme team and HCAI and AMR Divisional Business Operations teams. In addition to the current baseline, there is an estimated resource requirement of £6.5 to £8.9million RDEL per annum (of which comms campaigns are £3million per annum) and £5.25million CDEL via UKHSA groups to enact stretch NAP commitments. There are also a number of additional projects that would seek grant funding.

7. Key challenges

The key challenges below were progressed to some degree in the previous NAP, and work will continue. Whilst progress is being made, resources limit pace, for example staffing for expanded surveillance activity, costs for increased high-risk group testing, large-scale interventions including public awareness campaigns, and legacy systems reliance awaiting transition to newer infrastructure, for example EDAP, genomics pipelines.

7.1 Building UKHSA AMR resilience in a changing socio-economic landscape

It is crucial to build a cross-UKHSA AMR business model to support with business planning across UKHSA groups and divisions implementing the NAP with the ability to identify the full AMR costs and deliverables for the organisation.

7.2 Cross-sectoral integration with NHSE

NHSE is our closest partner in the delivery of the NAP, and we have several workstreams that are carried out in collaboration and/or that complement NHSE delivery of interventions. Our Primary Care Interventions Unit and Antimicrobial Stewardship and Antimicrobial Resistance and Prescribing teams have been on the forefront of this ongoing collaboration, working with NHSE and ESPAUR partners to develop and evaluate evidenced based interventions for primary and secondary care as well as community pharmacy. There are opportunities, as well as challenges, for more seamless integration of AMR diagnostic and investigatory services with NHSE and across the health sector, including action from surveillance, and collaborations with NHS-X.

7.3 UKHSA AMR data and analytical capabilities and national leadership

Timely access to analysis and interpretation of data is essential to combating AMR. We need to facilitate and maximise data sharing across UK nations. Cloud-based solutions have enabled greater scalability, but we need to advance our data availability and analysis for partners across the whole healthcare system if the data is to help drive action. Current forecasts of additional requirements of £0.5million RDEL and £4.25million CDEL per annum via Data, Analytics and Surveillance for the NAP, with wide applicability beyond AMR (dependent upon discovery and subject to change).

7.4 Strengthen UKHSA engagement with industry on AMR

This is key to the delivery of the NAP and UKHSA AMR strategic objectives. Work with industry and suppliers is currently carried out case by case. There are pockets of strong engagement and work in development, alongside areas that need strengthening, all needing mapped out within our new NAP stakeholder engagement framework. We have started work with the UKHSA commercial team and key partners (for example Association of the British Pharmaceutical Industry, IQVIA) but need to solidify approaches across UKHSA.

7.5 Building evidence-based interventions

We need observational or national trial evidence, alongside detailed modelling and economic evaluation, to develop evidence based, impactful interventions. In the next 5 years, we aim to close this evidence gap, supported by a significant advance in embedding knowledge mobilisation principles across all our AMR work, including learning form the COVID-19 pandemic, and translating knowledge into tangible outputs for policy and public health action to inform large scale, innovative population interventions including candidate vaccines for AMR. Focus will be to measure these impacts and provide a framework for continued evaluation, providing feedback in an iterative process.

7.6 How we can support the UK to be a better world leader on AMR

UKHSA plays an important role in the UK’s position as a world leader in surveillance and reference microbiology; this can be enhanced by strengthened cross-government AMR planning. AMR activities are increasingly integrated alongside existential threats of climate change, one health and future pandemic planning. Increasing temperatures drive increased population migration and pathogen spread and increasing contact with animal reservoirs facilitating AMR spread. These are new areas which need dedicated investment. UKHSA epidemiology and laboratory testing help underpin the world-leading UK antimicrobial products subscription model, a ‘pull’ market incentive from government to accelerate drug discovery, led by NHSE and the National Institute for Health and Care Excellence. UKHSA can increase international activity for a enhance global AMR surveillance, guidance, policy, and detection of emerging threats. These new areas require refocussing of resources and prioritisation of existing activity.