Japan’s G7 Presidency Can Raise the Visibility of Drug-Resistant TB and Malaria
May 19, 2016
As the Group of 7 (G7) leaders meet in Ise-Shima, Japan, from May 26-27, 2016, antimicrobial resistance (AMR) will be raised as an important health concern for G7 countries and the rest of the world. The Government of Japan, chair of the G7 for 2016, has recently prioritized AMR as a national and international health concern, and committed to continuing the G7’s engagement on AMR that was launched by Germany in 2015. Japan is in a prime position to expand the G7 discourse on AMR by explicitly including the needs of low- and middle-income countries (LMICs) and raising the visibility of drug-resistant tuberculosis and malaria on the AMR agenda. Drug-resistant TB and malaria both pose a risk to global health security, and a new report from the Review on Antimicrobial Resistance estimates that by 2050, a quarter of the total deaths from AMR could be due to drug-resistant TB.
The Government of Japan has signaled its intention to advocate for global health under its G7 presidency. In a December 2015 article in The Lancet, Prime Minister Shinzo Abe outlined Japan’s vision to improve global health through, first, the implementation of a global architecture that is capable of responding effectively to public health crises such as the Ebola epidemic, and second, through the formation of resilient and sustainable national health systems that would enable universal access to health care. Furthermore, he emphasized that resilient and sustainable national health systems include core public health capacities responsible for managing infectious disease challenges such as TB and AMR. The G7 Leaders’ Summit in May 2016 and the G7 Health Ministers meeting in September 2016 present new opportunities for further progress in the global campaign against AMR.
On April 18, 2016, in the lead-up to the G7 Summit, CSIS co-organized an AMR symposium in Japan with the Tokyo-based think tank Health and Global Policy Institute (HGPI). The event catalyzed robust engagement from United States and Japanese government officials, industry, academia, and non-governmental organizations (NGOs). The Japanese government had released its new national action plan to tackle antimicrobial resistance earlier that month, and the meeting proved a timely occasion for Japanese stakeholders to react to the AMR national action plan and exchange views directly with officials from the Japan Ministry of Health, Labour, and Welfare (MHLW). Speakers and participants also reflected on U.S.-Japan bilateral cooperation, ongoing regional and global initiatives, and current gaps in combating AMR.
The keynote address was delivered on behalf of Minister Yasuhisa Shiozaki by Dr. Kazunari Asanuma, MHLW Director of TB and Infectious Diseases. Minister Shiozaki had planned to attend the gathering but was called away by emergency earthquake response and recovery efforts in Kumamoto. Minister Shiozaki’s statement highlighted Japan’s commitment to numerical targets for reducing antimicrobial use, a multisectoral approach for addressing AMR, and international collaboration. Speakers on the first panel presented ongoing and future regional and global capacity-building initiatives, including efforts to create and integrate surveillance networks in the medical and agricultural sectors. The second panel detailed the challenges to antibiotics research and development (R&D) faced by Japanese and multinational pharmaceutical companies, including lack of international regulatory harmonization. A vigorous question and answer period emphasized the eagerness of Japanese stakeholders to engage with their government and with the U.S. on AMR challenges.
The Government of Japan has recently begun to prioritize AMR as a national and international health concern. When G7 leaders committed to developing and sharing their AMR national action plans at the 2015 G7 Summit in Germany, Japan was the sole G7 country that had not yet created a plan. Minister Shiozaki prompted MHLW officials to produce an analysis of national antibiotic use and burden of drug-resistant bacterial infections, and to coordinate development of a national AMR action plan across multiple relevant government ministries. Japanese officials were initially slow to identify AMR as an important national health challenge because Japan’s total antibiotic consumption by humans is relatively low – comparable to Germany among European Union countries – and Japan has low rates of the most worrisome resistant gram-negative bacterial infections such as carbapenem-resistant Enterobacteriaceae (CRE). However, Japan suffers from among the highest rates of penicillin-resistant infections and methicillin-resistant Staphylococcus aureus (MRSA) in the world. Thus, while Japan’s distribution pattern of resistant bacterial infections differs from many other developed countries, the government has now recognized AMR as an emerging national problem. Through increased dialogue with the governments of the UK, U.S., and other AMR champions, the Japanese government has acknowledged that AMR is an escalating international public health threat and welcomes an opportunity to play a leadership role in the global community.
Although Japan has only recently seriously taken up the mantle of AMR, officials have made efforts to understand the specific needs of low- and middle-income countries, which is a laudable step that should be amplified by the G7. Immediately preceding the CSIS-HGPI symposium, Japan hosted the first Asia-Pacific regional health ministers and experts meeting on AMR, held in Tokyo on April 14-16. The meeting was organized in collaboration with the World Health Organization (WHO) South-East Asia Regional Office and the Western Pacific Regional Office, with the goal of understanding the drivers of AMR across the Asia-Pacific region, including the needs of LMICs in the region. For example, while antimicrobial stewardship is a focus of discussion in many developed countries, adequate access to antimicrobials is still a significant challenge in many developing countries, where more deaths result from a lack of antibiotics than from antibiotic resistance. Additionally, many LMICs do not have adequate laboratory capacity to detect resistant infections and to inform an understanding of the country’s burden of resistance. Capacity-building initiatives such as the Global Health Security Agenda support countries in improving laboratory capacity and surveillance networks, and G7 countries can help accelerate these efforts. Dr. Larry Kerr, Director of the Office of Global Health Security at the U.S. Department of Health and Human Services Office of Global Affairs, proposed that the U.S. and Japan could offer technical assistance to LMICs for conducting a national risk assessment that would identify the pathogens of greatest concern within each country. G7 nations should, individually and collectively, endeavor to understand the specific AMR needs of LMICs and contribute to capacity-building efforts. By spearheading regional consensus-building on AMR, Japan has modelled one way of achieving this objective.
The spread of antimicrobial-resistant infections constitutes a potential global health security risk, and in order to effectively anticipate and neutralize that threat, it is critical that the global community pursue a broad AMR agenda. Although healthcare-associated bacterial infections are the primary focus of current AMR efforts in the U.S. and several other countries, a global risk assessment for AMR would also identify multidrug-resistant TB (MDR-TB) and artemisinin-resistant malaria as significant threats. Because of the way national and international health programs historically arose, programs covering TB, malaria, and other bacterial infections are often siloed, which is a barrier to developing policy recommendations and interventions that cut across programs and disease areas. The problem of silos is particularly acute in the U.S., as evidenced by the creation of a U.S. National Action Plan to Combat Antibiotic-Resistant Bacteria, and a separate companion National Action Plan to Combat MDR-TB. Yet, a deeper understanding of challenges can be gained by thinking across disease boundaries, and it may be more cost-effective in some cases to create a unified solution (e.g., a global R&D mechanism) that fits multiple disease areas, rather than multiple mechanisms with repetitive structures.
While the scope of the WHO Global Action Plan is broad and includes TB, malaria, and other bacterial infections, national and international policy design and implementation dialogues do not always include representatives from different programs. The CSIS-HGPI symposium was attended by participants currently working on TB from industry, NGOs, and international organizations, which helped to inform and enrich conversations. Japan has an ongoing focus on TB, including the recent development of the MDR-TB drug delamanid by a Japanese pharmaceutical company, Otsuka Pharmaceuticals. Because Southeast Asia is the epicenter of the emergence of artemisinin-resistant malaria, Japan’s leadership in the region helps government officials gain insight into the fight against drug-resistant malaria. At the conclusion of the Tokyo Meeting of Health Ministers on Antimicrobial Resistance in Asia, ministers of 12 countries, including China, India, Japan, Myanmar, and Thailand, issued a joint communique on AMR, emphasizing the threat of “spread of multidrug-resistant strains of malaria and tuberculosis among others”. 
As the G7 discusses AMR this year, it will likely focus on R&D of new antibiotics and stewardship of antimicrobials in humans and animals. But it is critical for G7 leaders and health ministers to remember that AMR represents a wide-ranging health security threat and that G7 countries have a responsibility to consider the needs of both developed and developing nations as officials contemplate future actions, which means a greater emphasis on addressing drug-resistant TB and malaria. Additionally, the G7 should commit to actions that accelerate capacity-building in LMICs and improve infection prevention and control worldwide, a critical step in preventing the emergence and spread of AMR. Japan should take full advantage of its historical engagement in global health, its unique position in the Asia-Pacific region, and its ongoing interest in universal health coverage, to assert a leadership role in G7 AMR deliberations that includes the needs of LMICs and a broad AMR agenda.