DR. YOUNGMAN: Thank you.

Now, if we can move to the next question, question five. Currently, there are global efforts in health and food security relating to antimicrobial resistance surveillance. How should NARMS be involved in international efforts? Can we start with you, Lyle?

DR. VOGEL: Sure. First off, I would like to commend all three arms of NARMS for the efforts that they have had in international cooperation and the attempts for international standardization and international assistance.

With that said -- and I better move away from my colleague here to my right from WHO -- I do think in the time of constraints for funding and other resources, that this is one area that we really need to look closely at a potential way where we need to cut funding. And the amount of attention that we are giving to international efforts.

It is important but, to me, it is not one of the top priorities of a national antimicrobial resistance monitoring system. So I don’t believe that funding for international efforts should come from a national program.

DR. YOUNGMAN: Thank you for your comments. Awa.

DR. AIDARA-KANE: Thank you. So I would like to say that WHO, FAO, and OIE, on request from Codex Alimentarius Commission are currently examining the issue of antimicrobial resistance arising from antimicrobial use in animals intended for food. So I think that NARMS is very important program for all these international organizations. And this integrated surveillance will help development of food safety standards and antimicrobial resistant management strategies.

WHO urges members states to implement antimicrobial surveillance system to first implement sound public health interventions, and also to enhance prudent practices in human and veterinary medicine.

And as some of the speakers have already said, foodborne diseases need to be addressed globally. So I think that there is no sense protecting your national public health if you don’t look at what is going on globally. I think that participating to a global effort is someway also participating in your national improvement of your public health.

So I have to say that NARMS should join other existing networks, like DANMAP, CIPARS from Canada, to share information. For example, emergence of multi-resistant material. We have already had international outbreaks. It is only through information sharing between existing network that we were able to trace the origin of international outbreaks. It is also a good way to coordinate and harmonize the format of data reporting at international level, which would be very helpful.

And I am also here to encourage NARMS to continue supporting the work of international organizations involved in foodborne surveillance in terms of training scientists, in terms of activities of Global Salm-Surv, and also other networks, like Resistvet Project in Mexico and other existing networks.

DR. YOUNGMAN: Thank you very much. Scott.

DR. MCEWEN: Yes, I would also like to commend the various branches for their international efforts. I think it is very important. I think NARMS really is kind of a goal standard and needs to continue to show leadership and help other countries get on-side. I think it has provided some excellent examples of where this has been positive, as is the support and collaboration with WHO and other international organizations.

I agree that AMR is a global problem, and we need global efforts to confront the problem. I think as one of the slides showed, that bacteria don’t respect international borders. So I kind of think of the intelligence analogy where, if you have got threats abroad, you need to have intelligence gathering efforts abroad.

So I would look at the development of these other national programs beyond the U.S. borders as part of that information gathering. So I think it does serve a national interest, United States. So, again, I would encourage participation. And it didn’t seem to me to be a large expenditure for the return on investment.

DR. YOUNGMAN: Thank you. Marissa.

DR. MILLER: I guess I have to jump on that last point, because for an investment of $100,000.00, there is a remarkable scope of activities that I think are very important. And I would, certainly, support continuing in the international global arena.

I think that it is important on a lot of levels. One is for predicting what may be headed our way. Obviously, DT104 is a good example of that. And there is just recently a very, very compelling story about -- it doesn’t relate to enteric pathogens, but the use of Amantidine in China for bird flu, which has made the emerging pandemic strain resistant to one of our first lines of therapies. So, I think we just have to know and be involved in what is going on around us.

And I think it is wonderful that NARMS has had a leadership role, and I would hope that that continues. I agree that NARMS is a goal standard. And, I would say, to me, the three most important areas are training, which sounds like you are fully engaged, standardization of lab methods, and reporting. So I think for the small investment, the wealth of information and collaborations that have resulted are well worth it.

DR. YOUNGMAN: Thank you very much. Sue.

DR. KOTARSKI: Yes, I would also like to underscore the comments for the relatively small investment, the extent to which it is played out in terms of our outreach programs. The involvement in the PulseNet. It is the ability to take them on a passive basis -- incomings, if you will, as the examples that Shaohua gave us today. I think that it is all worth it.

On the surface you say, well, it is a national antimicrobial resistance monitoring program. And from that standpoint, one might question whether or not the monies that are spent should be under the NARMS funding. But that is beyond my decision-making, or my recommendations.

So the question would come up but, obviously, going back to the concept that bacteria have no borders, pathogens have no borders, for our public health surveillance, it certainly is essential.

I do have a question as to whether or not we can -- for the investment we spend in Mexico for monitoring or setting up a surveillance program there, or an integrated surveillance program there, how that influences our ability to help our own public interests, or the Mexican public interests. There wasn’t sufficient information for me to understand that, but I am confident it probably does. There wasn’t enough time, I am sure you could have told us all, but it was just a short time to go over it.

DR. YOUNGMAN: Okay, thank you. Sean.

DR. ALTEKRUSE: I agree that one of the legacies of NARMS will be its extension internationally. And the thing is that the interpretive criterion and the micro broth dilution methods -- all these methods are in place. That was a tremendous amount of work to establish these sort of standards.

And what that means is that by proving these resources to other countries, they don’t have to reinvent the wheel. So there is a leveraging effect by what has already been accomplished. And, therefore, I consider it really critical that the experts in the NARMS system continue to help with training and consultation on all of those aspects. On laboratory methods, quality control, troubleshooting.

It seems like we heard several times that some of the labs had difficulty with Campy at the outset. It sounds kine of familiar. And then on reporting systems, because that has been something that we have struggled with and it looks like we are getting to a good point with it.

Also, Tom mentioned some of the outside sources of funding. And if we can help cultivate those networks for funding -- he mentioned the World Bank, the Japanese agency, local sort of -- what do they call it -- micro-economic -- micro-loans, and other creative methods. That is really worthwhile.