Developing a protocol on antimicrobial resistance through WHO’s pandemic treaty will protect lives in future pandemics

Globalization and Health Ruckert et al. Globalization and Health (2024) 20:10 https://doi.org/10.1186/s12992-024-01015-1 Open Access CO M M E N TA R Y Developing a protocol on antimicrobial resistance through WHO’s pandemic treaty will protect lives in future pandemics Arne Ruckert1* , Shajoe Lake1 and Susan Rogers Van Katwyk1 Abstract Addressing antimicrobial resistance (AMR) through the pandemic treaty is a crucial aspect of pandemic prevention, preparedness, and response. At the moment, AMR-related provisions in the draft text do not go far enough and will likely lead countries to commit to the status-quo of AMR action. We suggest that the protocol mechanism of the treaty proposed under Article 31 offers an opportunity to develop a subsidiary agreement (or protocol) to further codify the specific obligations and enforcement mechanisms necessary to meet the treaty’s AMR provisions. We also highlight experiences with previous treaty implementation that relied on protocols to inform design of a future AMR protocol. Introduction Antimicrobial resistance (AMR) is a natural evolutionary process, but can be accelerated by human activity, and occurs when bacteria, viruses, fungi and parasites no longer respond to antimicrobial medicines. AMR represents a key global governance challenge that requires equitable global coordination [1]. Existing governance mechanisms, including the International Health Regulations (IHRs) are limited in their ability to address AMR amidst deep fragmentation, insufficient governance infrastructure, and concerning global health inequities [2, 3]. Addressing AMR through the pandemic treaty must be a crucial aspect of pandemic prevention, preparedness, and response [4]. With the World Health Assembly’s May 2024 deadline for a pandemic treaty fast approaching, the Intergovernmental Negotiating Body recently released the fourth draft of the text [5]. While AMR is mentioned twice, the current text is not sufficient to safeguard the effectiveness of antimicrobials. The new pandemic treaty offers a path forward: the proposed protocol mechanism under consideration as Article 31 creates an opportunity to mitigate the impact of AMR on pandemic prevention, preparedness, and response [6, 7].1 Antimicrobials are a vital resource that must be preserved for responding to pandemic emergencies, as well as a potential source of future pandemics. At the same time, the use of antimicrobials during such emergencies may worsen AMR, with bacterial AMR estimated to globally have caused 1.29 million deaths, and being associated with almost five million deaths, in 2019 [8]. The latest draft of the pandemic treaty requires countries under Article 4(4)(g) “to take actions to prevent outbreaks due to pathogens that are resistant to antimicrobial agents, *Correspondence: Arne Ruckert 1 Global Strategy Lab, School of Global Health, York University, M3J 1P3 Toronto, ON, Canada 1 The relevance of the pandemic treaty to addressing AMR has previously been established [1, 4]. We are assuming for the purpose of this commentary that the pandemic treaty will impact global health governance practices, by facilitating better global collaboration and coordination in policy areas relevant to pandemic prevention, preparedness, and response. © The Author(s) 2024. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ruckert et al. Globalization and Health (2024) 20:10 and, in accordance with national context, develop and implement a national One Health [OH] action plan that includes an antimicrobial resistance component” [5]. These provisions provide a starting point but are too general to lead to the effective implementation of the necessary policy actions, and will likely lead countries to recommit to the status quo of AMR actions– including limited implementation and financing of AMR national action plans by states, and unclear AMR obligations for non-state actors in terms of managing antimicrobial use. Global policy coordination, to date, has been insufficient to address a One Health challenge of this magnitude. Creating a pandemic treaty without adequately addressing AMR would be counter-productive as life-saving antimicrobials can help manage the burden of future pandemic threats, including through the treatment of secondary bacterial infections often associated with pandemics [9, 10]. The protocol mechanism offers an opportunity to develop a subsidiary agreement to codify the specific obligations and enforcement mechanisms [11] necessary to meet the treaty’s AMR provisions [12]. An AMR protocol must address three key policy challenges Protocols are subsidiary formal agreements that often supplement, clarify, or provide additional provisions for general obligations outlined in the main treaty. While protocols operate as separate legal instruments, they are designed to be integrated with, and interpreted in conjunction with the main treaty text. An AMR protocol could be negotiated and adopted simultaneously, or subsequently to the pandemic treaty, and designed to address three of the most complex AMR policy challenges that require sustained global collaboration: the procedures and mechanisms to address antimicrobial stewardship; facilitating effective One Health surveillance systems; and building capacity for treaty implementation. Many existing treaties have used the protocol mechanisms to provide more detailed guidance for the implementation of treaty provisions, by outlining clear obligations and enforcement mechanisms [11]. As described below, design features of an AMR protocol under the pandemic treaty could be informed by the experiences of successful protocol use to advance treaty goals in the areas of stewardship, surveillance, and capacity building. Stewardship of antimicrobials Safeguarding the effectiveness of antimicrobials is essential to support global policy responses to future pandemics. An AMR protocol could develop globally harmonized rules governing which antim (...truncated)