Biregional Technical Consultation on Antimicrobial Resistance in Asia, Tokyo, Japan, 14-15 April 2016 : meeting report

14–15 April 2016 Tokyo, Japan Meeting Report Biregional Technical Consultation on Antimicrobial Resistance in Asia

Report Series Number: RS/2016/GE/10(JPN) English only MEETING REPORT BIREGIONAL TECHNICAL CONSULTATION ON ANTIMICROBIAL RESISTANCE IN ASIA Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC AND REGIONAL OFFICE FOR SOUTH-EAST ASIA Tokyo, Japan 14–15 April 2016 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines August 2016 2 NOTE The views expressed in this report are those of the participants of the Biregional Technical Consultation on Antimicrobial Resistance in Asia and do not necessarily reflect the policies of the conveners. This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Biregional Technical Consultation on Antimicrobial Resistance in Asia in Tokyo, Japan, 14–15 April 2016. 3 CONTENTS ABBREVIATIONS ................................................................................................................................ 4 SUMMARY ............................................................................................................................................ 5 1. Introduction ..................................................................................................................................... 6 1.1 Meeting organization ................................................................................................................. 6 1.2 Meeting objectives ..................................................................................................................... 6 2. PROCEEDINGS ............................................................................................................................. 6 2.1 Opening session ......................................................................................................................... 6 2.2 Threat of AMR .......................................................................................................................... 7 2.3 Actions to contain AMR in Asia-Pacific region ........................................................................ 8 2.4 Awareness raising: target groups and messages ........................................................................ 8 2.5 Slowing down AMR through stronger health systems: the role of universal health coverage .. 8 2.6 Fighting AMR: a key action for attaining the SDGs ................................................................. 9 2.7 Governance for multisectoral national plans for containment of AMR .................................... 9 2.8 Monitoring the implementation of national actions plans on AMR .......................................... 9 2.9 Opportunities in Asia-Pacific region to contribute to the global response to AMR ................ 10 2.10 Closing session ...................................................................................................................... 10 3. CONCLUSIONS AND RECOMMENDATIONS ........................................................................ 11 3.1 Conclusions ............................................................................................................................. 11 3.2 Recommendations ................................................................................................................... 11 3.2.1 Recommendations for Member States .............................................................................. 11 3.2.2 Recommendations for WHO ............................................................................................ 12 ANNEXES ............................................................................................................................................ 14 Keywords: Asia / Drug resistance / Microbial / Infection control / Regional health planning 4 ABBREVIATIONS AMR antimicrobial resistance ASEAN Association of South-East Asian Nations FAO Food and Agriculture Organization of the United Nations G7 Group of Seven JANIS Japan Nosocomial Infections Surveillance OIE World Organisation for Animal Health SDG Sustainable Development Goal WHO World Health Organization 5 SUMMARY The Biregional Technical Consultation on Antimicrobial Resistance in Asia, held on 14–15 April 2016, was organized in connection with the meeting on antimicrobial resistance (AMR) attended by ministers of health from countries in the Asia-Pacific region on 16 April 2016 in Tokyo, Japan. Discussions focused on moving forward with comprehensive policies and actions to implement national action plans on AMR appropriate to each country context and on opportunities for strengthening regional collaboration. Recommendations provided priority action areas for implementation of the communiqué issued by ministers of health on 16 April 2016. The emergence and spread of AMR threatens our ability to treat infections and, ultimately, the achievement of the Sustainable Development Goals (SDGs). Addressing this threat requires a whole- of-government political commitment and strategies to engage the general public, professionals and policy-makers across all sectors of society. Continued momentum to take action on AMR is imperative to ensure that antimicrobials remain effective for future generations. The meeting discussed the importance of the multisectoral and multidisciplinary approach within the framework of the “One Health” approach. Focused action moving towards universal health coverage, food security, sustainable agriculture and aquaculture practices, and environmental protection constitutes a harmonized approach for reaching the SDGs. Ultimately AMR can threaten national development agendas. In order to ensure multisectoral collaboration and actions to contain AMR, effective governance mechanisms are crucial at the national, regional and global levels. The meeting discussed the need for a robust framework to monitor and evaluate implementation of national action plans. Accountability at the regional and global levels can be achieved through reporting, information sharing and harmonization of surveillance and regulation. The meeting also considered the need for enhanced research and development of novel antimicrobials, vaccines and diagnostics. The meeting provided a unique opportunity to consider options for collaboration in the Asia-Pacific region. Collective action on AMR is an excellent model of an integrated and indivisible approach to achieving the SDGs. 6 1. INTRODUCTION 1.1 Meeting organization The Biregional Technical Consultation on Antimicrobial Resistance in Asia was held in Tokyo, Japan, 14–15 April 2016, with participants from the ministries of health and agriculture from 12 countries in the South-East Asia and Western Pacific Regions. On day 1, welcome messages were provided by the World Health Organization (WHO) and by a representative of the host country, Japan. Following the formal opening, the consultation was divided into eight sessions: 1) the threat of antimicrobial resistance (AMR); 2) actions to contain AMR in Asia; 3) advancing awareness raising – target groups and messages; 4) slowing down AMR through stronger health systems – the role of universal health coverage; 5) slowing down AMR – a key action for reaching the Sustainable Development Goals (SDGs); 6) governance for multisectoral national plans for containment of AMR; 7) monitoring the implementation of national action plans on AMR; and 8) opportunities in the Asia-Pacific region to contribute to the global response to AMR. 1.2 Meeting objectives The objectives of the meeting were: 1) to share experiences in developing national multisectoral plans to combat AMR and to identify attributes and approaches to develop and implement effective multisectoral national action plans; 2) to identify an action framework for implementing the ministerial communiqué on AMR in Asia and accelerate implementation of national and global action plans on AMR to be presented to the Group of Seven (G7) Summit and United Nations General Assembly in 2016; and 3) to provide opportunities to foster collaboration among countries within and across WHO regions. 2. PROCEEDINGS 2.1 Opening session Dr Vivian Lin, Director of the Division of Health Systems in the WHO Regional Office for the Western Pacific, delivered the opening remarks on behalf of Dr Shin Young-soo and Dr Poonam Khetrapal Singh, the WHO Regional Directors for the Western Pacific and South-East Asia Regions respectively. She emphasized the opportunity that the consultation presented in fostering cooperation and partnerships among sectors, countries and international organizations in the Asia-Pacific region to ensure access to effective antimicrobials for future generations through actions to support the Communiqué of Tokyo Meeting of Health Ministers on Antimicrobial Resistance in Asia. 7 Dr Masato Kasuga, President of the National Centre for Global Health and Medicine, Japan, provided introductory remarks on behalf of the Ministry of Health and Labour Welfare, Japan, highlighting the importance of tackling AMR and Japan’s commitments through the launch on 5 April 2016 of the Japan National Action Plan on Antimicrobial Resistance 2016–2020. Following the introduction of participants, Dr Klara Tisocki, Coordinator of the Essential Medicines and Health Technologies Unit at the WHO Regional Office for the Western Pacific, introduced the meeting objectives and agenda. Dr Graeme Barden was appointed as chair and Mr Anshu Prakash as vice-chair. Dr Christopher Lee and Dr Harry Parathon were appointed as joint rapporteurs for the meeting. 2.2 Threat of AMR Dame Sally Davies presented AMR as a major threat to development requiring urgent action across sectors and countries that went beyond dialogue and political commitment. She acknowledged the unprecedented amount of work that had already taken place since 2013 and the current momentum on moving the AMR agenda forward, highlighting that AMR would be an agenda item in upcoming meetings, including the G7 Summit and the United Nations General Assembly. She introduced the Fleming Fund, the United Kingdom official government assistance on AMR, which aimed to help low-income countries build laboratory capacity for surveillance and develop national action plans. She concluded her presentation by emphasizing that everyone had a role to play, and there was no room for complacency in tackling AMR. Dr Keiji Fukuda shared the WHO perspective on past, present and future actions to tackle AMR as a human health security threat. He gave a summary of measures taken thus far to tackle AMR, including consultations held, guidelines developed and national and regional initiatives stemming back to 1959. Dr Fukuda indicated that 2016 was a pivotal year for actions at the technical and political level, and the profile of AMR was being raised, with the high level of political engagement exemplified by the United Nations General Assembly putting AMR on their agenda. He stressed that for countries, the development and implementation of national action plans on AMR was the single most important critical action to be taken. Dr Katinka de Balogh presented the perspective of the Food and Agriculture Organization of the United Nations (FAO) on the threat of AMR in relation to food security. With the rapid population increase in Asia there had been an immense growth in meat production, which would be intensified further to meet the growing demand for food. Consequently there was a need for safe and sustainable practices, including the prudent use of medicines in the animal and agricultural sector. She highlighted the interconnectivity among various sectors, including human health and animal health, and stressed the need to keep in mind the role of the environment as a common denominator in the cycle of AMR. In conclusion, Dr de Balogh said there was a need to find joint solutions across sectors and countries through a One Health approach. Dr Mary Joy Gordoncillo provided the World Organisation for Animal Health (OIE) perspective on the challenges of AMR in Asian livestock. A proportion of countries in the Association of South-East Asian Nations (ASEAN) still lacked legislation on the use of antimicrobials in livestock. She outlined the core activities of OIE with regard to AMR, including updating standards and guidelines, updating the OIE list of antimicrobial agents, and developing a global database on antimicrobial use in animals. A survey was currently being conducted and would be sent annually to monitor progress over time on the use of antimicrobials in animals. OIE was also actively working on infection prevention and control, optimizing use of antimicrobials, and raising awareness. 8 Dr Tetsuo Asai elaborated on the use of antibiotics in the animal sector and its risk to human health, noting that antibacterial agents were essential for controlling bacterial disease in both animals and humans. Outlining the governmental structure for ensuring food safety in Japan, he said that the Food Safety Commission, an independent agency, had been established in 2003 to undertake risk assessments and provide recommendations to all relevant ministries. Japan had also set up the Japanese Veterinary Antimicrobial Resistance Monitoring System, which had started collaboration with the Japan Nosocomial Infections Surveillance (JANIS) for integrated surveillance in a One Health context. Dr Asai concluded his presentation by highlighting how the effect of a voluntary ban on the off-label use of ceftiofur in poultry in 2012 resulted in a significant decrease in resistance rates, as demonstrated by the Veterinary Antimicrobial Resistance Monitoring System. 2.3 Actions to contain AMR in Asia-Pacific region Dr Vivian Lin gave a presentation on a framework for action to support the Communiqué of Tokyo Meeting of Health Ministers on Antimicrobial Resistance in Asia. She emphasized that multisectoral collaboration and actions could be achieved through effective governance mechanisms that identified AMR as a development issue. Working towards universal health coverage would build resilient health systems to contain AMR in the human sector. Beyond human health, the One Health approach could identify and implement sustainable actions across the human, animal, agriculture and environment sectors. She concluded that in order to take integrated and collaborative action on AMR, governance mechanisms at the national, regional and global levels should place AMR within the development agenda in the context of working towards achieving the SDGs. 2.4 Awareness raising: target groups and messages Dr Visanu Thamlikitkul gave a presentation on Thailand’s experience in raising awareness of the faceless threat of AMR. He introduced the Thailand Antimicrobial Resistance Containment and Prevention Programme 2013–2016, which focused on stopping the emergence, transmission and acquisition of AMR bacteria in the hospital and community settings as well as in the animal sector. The results of an awareness survey conducted in four pilot communities showed that communities were not aware of or did not understand AMR. Thailand’s AMR core campaign focused on the slogan “Stopping AMR is everybody’s business”, and used trained village health volunteers to raise awareness among communities. Following the presentation, a panel discussion was held on advocacy through annual antibiotic awareness week. 2.5 Slowing down AMR through stronger health systems: the role of universal health coverage Dr Vivian Lin gave a presentation on an integrated approach to AMR and universal health coverage. She introduced the challenges faced in low-income countries, where dispensing of antimicrobials often depended on the funds available to the buyer. It was important to build sustainable and resilient health systems that provided equitable access to effective antimicrobials. In concluding her presentation, she emphasized that the interdependent drivers for AMR required that universal health coverage strategies took AMR into account. Professor Ramon Shaban gave a presentation on the role of governance in dealing with AMR, and ensuring that efforts were systematic, coordinated and cross-sectoral. Building robust national systems centred on a One Health approach required six elements, namely antimicrobial stewardship programmes; infection prevention and control; governance and regulation to ensure access to and quality of antibiotics; measuring the burden of infectious disease; research and development; and 9 shaping community expectations with regard to antibiotics. Professor Shaban concluded by re- emphasizing the need to address AMR through the five key attributes of universal health coverage. Following the presentation, a panel discussion was held on addressing AMR in the context of progress towards universal health coverage. 2.6 Fighting AMR: a key action for attaining the SDGs Professor Otto Cars gave a presentation on the threat that AMR posed to sustainable development. Antibiotics were the cornerstone of basic health care, maternal and child health, and modern medicine. He introduced the development dialogue paper Antimicrobial resistance: a threat to the world’s sustainable development,1 which drew direct linkages between AMR and SDGs 1, 2, 3, 6, 8, 12 and 17. Access to effective antimicrobials was a fundamental component of all health systems (SDG 3). In addition, AMR struck hardest on the poor as a consequence of the loss of first-line treatments with the growth of AMR, leading to increasing costs of effective treatment options (SDG 1). The cost of antibiotic resistance also reached sectors beyond health, with implications for societal and economic growth (SDG 8). The increase and spread of AMR was directly correlated to the non-human use of antibiotics (SDG 2), with consequences for access to clean water and sanitation due to such factors as the leakage of antibiotic residues into water systems (SDG 6). In conclusion, he said that tackling AMR required balancing universal access, innovation, and conservation of antimicrobials (SDG 12), which required multistakeholder partnership (SDG 17). Following the presentation, a panel discussion was held on AMR as a development agenda requiring national governance for a multisectoral approach. 2.7 Governance for multisectoral national plans for containment of AMR Dr Haruo Watanabe gave an introductory presentation on AMR as a regional health security challenge requiring urgent national actions that addressed the five strategic objectives of the Global Action Plan on Antimicrobial Resistance. The rapid spread of resistance highlighted by carbapenem-resistant enterobacteriaceae was limiting the choice of antibiotics for treatment, requiring the increased use of last-resort antibiotics. He shared a recent Lancet study on the emergence and dissemination of plasmid-mediated colistin-resistant (mcr-1) enterobacteriaceae and the potential genetic transfer from humans to animals through the food chain. Dr Haruo stressed the urgent need for action to address AMR through a multisectoral One Health approach. The introductory presentation was followed by country presentations reflecting on governance of AMR, with a focus on national mechanisms, challenges and next steps for development and implementation of national action plans. The following countries provided brief country presentations: Australia, Bangladesh, China, India, Indonesia, Japan, Malaysia, Myanmar, the Philippines, the Republic of Korea, Thailand and Viet Nam. 2.8 Monitoring the implementation of national actions plans on AMR Dr Keiji Fukuda discussed monitoring considerations for national action plans on AMR. It was important to build monitoring and evaluation systems for AMR that were based on existing systems and that worked towards harmonization across sectors and facilitated assessment and decision- making. Indicators should be well defined and limited in number, and should draw upon existing 1 Jasovsky D, Littmann J, Zorzet A, Cars O. Antimicrobial resistance: a threat to the world’s sustainable development. Development Dialogue Paper No. 16. 10 indicators and data sources. He provided the example of the assessment of the capacities of International Health Regulations as an existing monitoring and evaluation tool. He concluded that while monitoring was essential, there were challenges to the adoption of a monitoring and evaluation approach that was applicable across sectors and countries and provided a coherent picture. Dr Roderico Ofrin presented a roadmap for the development and implementation of AMR national action plans that were aligned with the Global Action Plan on Antimicrobial Resistance. Key elements of the roadmap include development of an AMR committee, a review of challenges, identification of gaps and opportunities, development of the plan, endorsement of the plan by relevant ministries and sectors, and incorporation of the plan into existing structures and activities. He introduced a monitoring scorecard that was currently being developed by the WHO Regional Office for South-East Asia for the development and implementation of national action plans on AMR. 2.9 Opportunities in Asia-Pacific region to contribute to the global response to AMR Dr Keigo Shibayama discussed the importance of robust surveillance systems across Asia to combat AMR. He provided an insight into Japan’s experience with JANIS, which included approximately 1800 participating hospitals. The challenge for surveillance was bridging the gap between the human and animal sectors. One solution was for separate surveillance systems for human and animal health with a joint platform for data analysis, training and prioritization of AMR microorganisms. Japan was currently developing a One Health surveillance system that would incorporate surveillance data from the human, animal, food and environment sectors, along with antibiotic use. He concluded by highlighting the importance and challenges of harmonizing surveillance systems across countries through a regional or global surveillance system. Following the presentation, a panel discussion was held on surveillance data sharing across regions and globally. Dr Junko Sato gave a presentation on capacities in the Asia-Pacific region for the development of new technologies to control AMR. She alluded to some major international initiatives, such as the 10 x ’20 initiative to foster the development of 10 new antibiotics by 2020. Funding was a major challenge for the development of new diagnostics and antimicrobials. Options included repurposing old antibiotics or using combination therapies, though that was dependent on their availability on the market. She also highlighted other innovative approaches, including development of a global consortium for research and development of new antimicrobials, alternative treatment options such as bacteriophages, and new diagnostic tools. Following the presentation, a panel discussion was held on research and development of new diagnostics and antimicrobials, and regional capacities and potential regional mechanisms to stimulate research and development. 2.10 Closing session The meeting summary and recommendations were reviewed and adopted by the meeting participants. Professor Otto Cars and Dr Arun Thapa, Director of Programme Management, WHO Regional Office for South-East Asia, provided closing remarks. Professor Cars applauded participants for the level of understanding and the pace of ongoing work on AMR. He acknowledged the translation from dialogue to real action on AMR in the Asia-Pacific region. Dr Thapa summarized the framing of AMR in the context of universal health coverage, the One Health approach and the SDGs. There was a substantial amount of work to be done; however, the first step was to develop national action plans and accelerate progress on combating AMR together through friendship and trust. The 11 implementation of the Communiqué of Tokyo Meeting of Health Ministers on Antimicrobial Resistance in Asia was a unique opportunity for countries in the Asia-Pacific region to lead the agenda on AMR. 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions Discussions focused on moving forward with comprehensive policies and actions to implement national action plans on AMR appropriate to each country context, and on opportunities for strengthening regional collaboration. Recommendations provided priority action areas for implementation of the communiqué issued by ministers of health on 16 April 2016. Addressing AMR requires a whole-of-government political commitment and strategies to engage the general public, professionals and policy-makers across all sectors of society. Continued momentum to take action on AMR is imperative to ensure that antimicrobials remain effective for future generations and for the achievement of the SDGs. A multisectoral and multidisciplinary approach is required within the framework of One Health to contain AMR. Taking action on AMR to move towards universal health coverage, food security, sustainable agriculture, aquaculture practices, and environmental protection constitutes a harmonized approach for attaining the SDGs. Effective governance mechanisms are crucial at the national, regional and global levels to ensure multisectoral collaboration and action to contain AMR. There is a need for a robust framework to monitor and evaluate implementation of national action plans. Accountability at the regional and global levels can be achieved through reporting, information sharing and harmonization of surveillance and regulation. There is also a need for enhanced research and development of novel antimicrobials, vaccines and diagnostics. The Biregional Technical Consultation on Antimicrobial Resistance in Asia provided a unique opportunity to consider options for collaboration in the Asia-Pacific region. Collective action on AMR is an exemplar of an integrated and indivisible approach to achieving the SDGs. 3.2 Recommendations 3.2.1 Recommendations for Member States 1) Member States are encouraged to organize ongoing public campaigns to increase awareness and change behaviour on sanitation, hygiene, infection prevention and control practices, and the responsible use of antimicrobials. 2) Member States should hold annual antibiotic awareness week campaign activities in all countries to deliver messages that address the challenges across the human, animal and agricultural sectors. 3) Member States may mandate inclusion of AMR stewardship into education programmes for personnel working in human and animal health, and agricultural sectors. 4) Member States should seize opportunities through various policy entry points to stimulate ongoing political commitment, such as finishing the Millennium Development Goals and accelerating progress on the Sustainable Development Goals. 5) Member States should improve regulatory controls and health financing mechanisms, including quality assurance from manufacturers to authorized retailers and reducing financial incentives that 12 contribute to inappropriate use, in order to ensure equitable access to quality antimicrobials to all who need them. 6) Member States are encouraged to implement antimicrobial stewardship programmes with full national coverage to improve prescribing practices of health care providers and ensure the rational use of antimicrobials. 7) Member States should develop and disseminate guidelines for the diagnosis and treatment of common infectious diseases that take into account findings from AMR surveillance. 8) Member States are strongly encouraged to develop and implement strategies to strengthen infection prevention and control in community and health care settings. 9) Member States should enact and enforce regulation of antimicrobials and control of the supply chain (including safe disposal and environmental controls) for humans, animals, agriculture and aquaculture. 10) Member States may develop and strengthen reliable, quality-assured surveillance systems to monitor the trends of drug-resistant pathogens and antimicrobial use in humans and animals. 11) Member States are encouraged to limit the use of critically important antimicrobials for human health in food systems by improving the stewardship of antibiotics by animal health providers and promoting sustainable agricultural practices. 12) Member States may optimize and expand vaccination programmes that can contribute to the prevention of AMR. 13) Member States may consider promoting a concerted multisectoral food chain approach using internationally recognized standards and guidelines, such as the Codex Alimentarius and the OIE standards and guidelines. 14) Member States are encouraged to regulate the production and domestic and international distribution of active pharmaceutical ingredients for antimicrobials and medicated feed. 15) Member states are encouraged to enforce prescription or veterinary-equivalent-only sales of antimicrobials in human and veterinary medicine. 16) Member States should strengthen regulations governing the use of critically important antimicrobials, based on scientific risk assessments, and phase out the use of antimicrobials as growth promoters in animals in the absence of risk analysis. 17) Member States may increase commitments for research and development and innovation to facilitate investments through a combination of incentives for new antimicrobials, diagnostics, vaccines and other interventions in human and animal health. 3.2.2 Recommendations for WHO 1) WHO is requested to promote, together with FAO and OIE, annual antibiotic awareness week campaign activities in all countries to deliver messages that address the challenges across human, animal and agricultural sectors. 2) WHO is requested to continue to support Member States in the development and implementation of multisectoral national action plans on AMR. 3) WHO is requested to foster, in collaboration with FAO and OIE, regional collaboration and information sharing across sectors and countries on developing and implementing national action plans on AMR. 13 4) WHO is requested to hold the second biregional technical consultation on AMR in Asia in 2017. Annex 1. List of Participants 1. PARTICIPANTS WESTERN PACIFIC REGION Australia Mr Graeme Barden, Assistant Secretary, Health Protection Policy, Department of Health, GPO Box 9848, Canberra ACT 2601, Telephone: (02) 6289 2626, Email: Graeme.barden@health.gov.au Dr Jill Millan, Director, One Health and Epidemiology, Department of Agriculture and Water Resources, 18 Marcus Clarke St., Canberra ACT 2601, Telephone: (02) 6272 3933, Email: jill.millan@agriculture.gov.au China Dr MA Xiaojun, Vice Director, Department of Infectious Diseases, Peking Union Medical College Hospital (East), No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, Telephone: +8613911378823, Email: drmaxiaoujun@sina.com Dr SONG Junxia, Division Director, Divisionof Sceince, TEcnology and International Cooperation, Veterninary Bureau, Ministry of Agricutlure, No. 11 NongZhanNanLi, Beijing, Telephone: 010-59191402 Dr XU Shixin, Division Director, China Institute of Veterinary Drug Control, Zhongguancun South Street #8, Haidian District, Beijing 100081, Telephone: 86 10 62103658, Email: xushixin@ivdc.org.cn Dr ZHOU Jun, Commissioner, Department of Medical Administration, National Health and Family Planning Commission, 1 Nanlu, Xizhimenwai, Beijing, Telephone: 0086-10-6879203, Email: zj2034@126.com Japan Dr Keishi Abe, Chief, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Telephone: +81 90 78980189, Email: abe-keishi@mhlw.go.jp Dr Satoshi Ezoe, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: ezoe-satoshi@mhlw.go.jp Dr Yasuamsa Fukushima, Director General, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: fukushima-yasumasa99@mhlw.go.jp Dr Masahiko Hayashi, Director for Animal Drug and Feed, Animal Products Safety Division, Food Safety and Consumer Affairs Bureau, Ministry of Agriculture, Forestry and Fisheries, 1-2-1, Kasumigaseki, Chiyoda-ku, Tokyo, Email: masahiko_hayahsi970@maff.go.jp Dr Mototaka Hiki, Chief, Animal Products Safety Division, Food Safety and Consumer Affairs Bureau, Ministry of Agriculture, Forestry and Fisheries, 1- 2-1, Kasumigaseki, Chiyoda-ku, Tokyo, Email: mototaka_hiki770@maff.go.jp Dr Toshiro Kawashima, Councilor (Deputy Director-General, Food Safety and consumer Affairs Bureau) Minister's Secretariat, Chief Veterinary Officer, Ministry of Agriculture, Forestry and Fisheries, 1-2-1, Kasumigaseki, Chiyoda-ku, Tokyo Dr Masami Miyakawa, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Telephone: +81 03 3595 2404, Email: miyakawa-masami@mhlw.go.jp Dr Yukiko Nakatani, Director, Pandemic Influenza Preparedness and Response, Health SErvcie Bureau, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: nakatani-yukiko@mhlw.go.jp Dr Takeshi Nishida, Association Director, Animal Products Safety Division, Food Safety and Consumer Affairs Bureau, Ministry of Agriculture, Forestry and Fisheries, 1-2-1, Kasumigaseki, Chiyoda-ku, Tokyo 100-8915, Email: takeshi_nishida670@maff.go.jp Dr Yui Sekitani, Deputy Director, International Affairs Division, Minister’s Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: sekitani-yui@mhlw.go.jp Dr Tatsuro Sekiya, Deputy Director, Animal Products Safety Division, Food Safety and Consumer Affairs Bureau, Ministry of Agriculture, Forestry and Fisheries, 1-2-1, Kasumigaseki, Chiyoda-ku, Tokyo 100-8915, Email: tatsuro_sekiya070@maff.go.jp Dr Jun Sugihara, Medical Officer, Tuberculosis and Infectious Diseases Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: sugihara-jun@mhlw.go.jp Dr Yasuhiro Suzuki, Assistant Minister for Technical Affairs and Chief Global Health Officer, Minister’s Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: suzuki-yasuhiro@mhlw.go.jp Dr Naoko Yamamoto, Assistant Minister for Global Health, Minister’s Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: yamamoto-naoko@mhlw.go.jp Dr Rain Yamamoto, Association Director, Animal Products Safety Division, Food Safety and Consumer Affairs Bureau, Ministry of Agriculture, Forestry and Fisheries, 1-2-1, Kasumigaseki, Chiyoda-ku, Tokyo 100-8915, Email: rain_yamamoto300@maff.go.jp Mr Hiroyuki Yamaya, Director, Office of International Cooperation, International Affairs Division, Minister’s Secretariat, Ministry of Health, Labour and Welfare, 1-2-2 Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Email: yamaya-hiroyuki@mhlw.go.jp Republic of Korea Dr Cho Enhi, Director, Division of Infectious Disease Control, Korea Center for Disease Control and Prevention, Osong Health TechnologyAdmnistration Complex, Osongsaengmyeong2(i)-ro, Osong-eup, Heungdeok-gu, Cheongiu- city, Telephone: 82 43 719 7120, Email: cho6404@korea.kr Dr Yong-Sang Kim, Director, Animal Health Management Division, Ministry of Agriculture, Food and Rural Affairs, 94 Dasom2-ro, Government Complex-Sejong,, Sejong-si 30110, Telephone: +82-44-201-2371, Email: yskim0621@korea.kr Dr Suk-Kyung Lim, Bacterial Disease Division, Animal and Plant Quarantine Agency, 175, Anyang-ro, Manan-gu, Anyang-si, Gyeonggi-do 430-757, Telephone: +82 031 467 1770, Email: imsk0049@korea.kr Dr Hyunjoo Pai, Professor, Division of ID, College of Medicine, Hanyang University, 17 Haengdang-dong,Seongdong-gu, Seoul, Republic of Korea, Telephone: 82 2 2290 8356, Email: paihj@hanyang.ac.kr Malaysia Dr Noor Asyikin Abu, Veterinary Officer, Makmal Kesihatan Awan Veterinar, Jabatan Perkhidamatan, Jalan Nilai-Banting, 43900 Sepang, Selangor, Telephone: 60387068311, Email: asyikin@dvs.gov.my Dr Norazah Ahmad, Clinical Microbiologist & Head of Bacteriology Unit, Institute for Medical Research, Jala Pahang, 50588 Kuala Lumpur, Telephone.: 03 26162650, Email : norazah@imr.gov.my Dr Christopher Lee Kwok Choong, Head, Infectious Disease Unit, Sungai Buloh Hospital, Specialist Office, level 2, Hospital Sungai Buloh, Jalan Hospital, 4700 Sungai Buloh Selangor, Tel. No.: 03 61454333, Email : chrislee@moh.gov.my Dr Redzuan Bin Ibrahim, Head of Biologics and Veterinary Drug Control Unit, Department of Veterinary Services, Wisna Tani, Level 5, Podium Block 1A Lot 4G1, Precint 4, Federal Government Administration Centre, 62630 Putrajaya, Telephone: 603 88702099, Email: redzuan@dvs.gov.my Philippines Dr Celia Carlos, Director III, Research Institute for Tropical Medicine, 9002 Research Drive, FCC Compound, Alabang, Muntinlupa City, Telephone: +63 2 8099763, Email: ccarlosphl@yahoo.com Ms Anne Julienne Genuino, Senior Health Programme Officer, Department of Health, Building 15, 3/F, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, Telephone: + 63 2 711 2589, Email: ajuliennemgenuino@gmail.com Dr Minda Manantan, Executive Director, National Meat Inspection Service, No. 4 Visayas Avenue. Barangay Vasra, Quezon City, Telephone: + 632 924 7980, Email: minda.manantan@yahoo.com Dr January Nones, Chief Meat Control Officer, National Meat Inspection Service, No. 4 Visayas Avenue. Barangay Vasra, Quezon City, Telephone: +632 921 4473, Email: jgmagcalas@gmail.com Viet Nam Dr Hoang Huong Giang, Deputy Head of Animal Feed Division, Department of Livestock Production, Cuc Chan nuoi, 16 Thuy Khue, Tay Ho, Ha Noi, Telephone: +84 913344334, Email: gianghoang97@yahoo.com Ms Le Thi Hue, Deputy Head, Division of Veterinary Drug Management, Department of Animal Health, 15/78 Giai phong Street, Dong Da District, Ha Noi, Telephone: +84 4 38697150, Email: lehue1973@gmial.com Dr Tran Thi Giang Huong, Director-General, International Cooperation Department, Ministry of Health, 138A, Giang Vo Street, Ba Dinh District, Ha Noi, Tel. No.: +84 983319965, Email: gianghuong_tran2002@yahoo.com Dr Luong Ngoc Khue, General Director, Department of Medical Service Administration, Ministry of Health, 15C, Dao Tan Street, Ba Dinh District, Ha Noi, Telephone: +84 919121818, Email: khUebyt2yahoo.com SOUTH-EAST ASIA REGION Bangladesh Md Habibur Rahman Khan, Joint Secretary, Ministry of Health and Welfare, Hatimara, Shardaganj, Joydebpur, Gazipur, Telephone: +8801821716162, Email: hbr@yahoo.com Dr Hossan Md. Salim, Upazila Livestock Officer, Livestock Economic Section, Department of Livestock Services, Dhaka-1215, Telephone: 90932, Email: hmsalim@gmail.com Professor Dr Abul Khari Mohammad Shamsuzzaman, Director, Disease Control, Directorate General of Health Services, Ministry of Health and Family Welfare, Mohakhli, Dhaka 1212, Telephone: +8801715566084, Email: zamantushar@gmail.com Mr Kazi Wasiuddin, Joint Secretary, Ministry of Fisheries and Livestock, Building No. 06, 5th Floor, Bangladesh Secretariat, Dhaka-1000, Telephone: 01715049051, Email: wasiuddin4145@gmail.com India Dr Anshu Prakash, Joint Secretary, Department of Health and Family Welfare, Mirman Bhawan, New Delhi 110011, Telephone: 23061195, Email: anshuprakashias@gmail.com Dr Sunil Gupta, Additional Director, National Center for Disease Control, 22 Sham Nath Marg, New Delhi 110054, Telephone: 011-42051447, Email: drsunilgupta.ncdc@gmail.com Dr Kamini Walia, Scientist E, Indian Council of Medical Research, Ansarinagar, New Delhi 10029, Telephone: +919899897978, Email: waliakamini@yahoo.com Indonesia Dr I Ketut Diarmita, Director of Animal Health, Kantor Pusat Kemeterian Pertanian, Gd. C Lantai 9 Pasar Minggu, Jakarta Selatan, Telephone: +6281339730008, Email: iketutdiarmita56@yahoo.com Dr Harry Parathon, Chief of Antimicrobial Resistance Control Committed, Ministry of Health, Sidoserm V/10, Surabaya 60239, Telephone: +62 81 1314571, Email: hparathon@yahoo.com Professor Dr Drh I Wayan TEguh Wibawan, MS, Expert Committee of Livestock and Animal Health Services, Faculty of Veterinary Medicine, Bogor Agricultural University, animal Expert commission, Ministry of Agriculture, J1. Harsono RM. No. 2, Ragunan, Daerah Khusus Ibukota Jakarta, Email: teguhwibawan@yahoo.co.id Dr Bambang Wibowo, Sp. OG (K) MARS, Director General of Health Services, J1. H.R, Rasuna Said Blok, X5 kav 4-9, Jakarta, Telephone: +62 2 151201590, Email: bwibowo.spog@gmail.com Myanmar Dr Ye Htut Aung, Pro-Rector, University of Veterinary Science, Yezin, Telephone: 009 9 2173846, Email: yehtutaung78@gmail.com Professor Myint Han, Director General, Department of Medical Services, Ministry of Health, Nay Pyi Taw, Email: drmyinthan201@gmail.com Dr Ok Kar Soe, Deputy Director, Animal Health and Development, Office 36. Livestock Breeding and Veterinary Department, Nay Pyi Taw, Telephone: 95 67 408020, Email: lbvd@mptmail.net.mm Dr Win Thein, Director, National Health Laboratory, Department of Medical Services, Ministry of Health, Nay Pyi Taw, Telephone: +95 9 252103864, Email: winthein60@gmail.com Thailand Dr Sasi Jaroenpoj, Head of Animal Feed and Veterinary Product Standard Section, Animal Feed and Veterinary Products Control Division, Department of Livestock Development, 69/1 Phaya Thai Road, Thanon Phaya Thai, Ratchathewi, Bangkok 10400, Telephone: 66 2 159 0406 ext. 111, Email: sasijaroenpoj@yahoo.com Associate Professor Varunee Jinaratana, Deputy Director-General, Department of Medical Services, 88/23 Tiwanon Road, Taladkwan, Muang, Nonthaburi 11000, Telephone.: 66 2 591 5231, Email: jvarunee@hotmail.com Dr Thanabadee Rodsom, Director, Animal Feed and Veterinary Products Control Division, Department of Livestock Development, 69/1 Phaya Thai Road, Thanon Phaya Thai, Ratchathewi, Bangkok 10400, Telephone: 662 159 0406 ext. 101, Email: nuifqc9@hotmail.com Dr Nithima Sumpradit, Pharmacist, Professional Level, Bureau of Drug Control, Food and Drug Administration, Thiwanon Road, Nonthaburi 11000, Telephone: 66 2 590 7165, Email: nithima@fda.moph.go.th 2. TEMPORARY ADVISERS Dr Tetsuo Asai, Professor, Veterinary Medicine, Gifu University, 1-1 Yanagito Gifu City Gifu, Japan Telephone: +81 58 293 2997, Email: tasai@gifu-u.ac.jp Dr Otto Cars, Senior Professor, Infectious Diseases, Founder and Senior Adviser, ReAct on Antibiotic Resistance, Uppsala University, 75105 Uppsala, Sweden, Telephone: + 46 70 8920203, Email: otto.cars@medsci.uu.se Professor Dame Sally Davies, Chief Medical Officer, Richmond House, 79 Whitehall, London SW1A 2NS, United Kingdom, Email: sally.davies@dh.gov.uk Professor Ramon Shaban, Director, Griffith Graduate Infection Control Programs, PO Box 96, Fortitude Valley, Queensland, Australia 4006, Telephone: +617 37356463, Email: r.shaban@grifith.edu.au Dr Keigo Shibayama, Director, Department of Bacteriology, National Institute of Infectious Diseases 4-7-1 Gakuen, Musashimurayama, Tokyo, Japan, Telephone: +81 42561 0771, Email: keigo@niid.go.jp Dr Visanu Thamlikitkul, Head, Division of Infectious Diseases, Siriraj Hospital, Mahidol University 2 Wanglung Road, Bangkok 10700, Telephone: 66818206271, Email: visanu.tha@mahidol.ac.th Dr Haruo Watanabe, Director General, National Institute of Infectious Diseases, 4-8-22 Sugita Isogo-ku, Yokohama City, Japan, Telephone: +81 45 776 2258, Email: watanabe-haruo@jcom.home.ne.jp 3. REPRESENTATIVES ADB Dr Douglas Ball, Consultant – Pharmaceutical Regulatory Affairs, ADB Avenue, Mandaluyong City 1550, Philippines, Telephone.: +63 2 6324444, Email: dball.consultant@adb.org Professor Soonman Kwon, Technical Advisor (Health), ADB Avenue, Mandaluyong City 1550, Telephone: +63 2 6326404, Email: skwon@adb.org FAO Dr Katinka de Balogh, Senior Animal Health and Production Officer, Regional Office for Asia and the Pacific, 39 Phra Atit Road, Phranakon, Bangkok 10200, Thailand, Telephone: 66 2697 4323, Email: katinka.debalogh@fao.org OIE Dr Mary Joy Gordoncillo, Science and One Health Coordinator, 69/1 Phaya Thai Road, Ratchathewi, 10400 Bangkok, Thailand, Telephone: +66 2 6534864, Email: m.gordoncillo@oie.int Dr Hirofumi Kugita, Regional Representative for Asia and the Pacific, World Organisation for Animal Health, Food Science Building 5F, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan, Telephone: +81 3 5805 1931, Email: h.kugita@oie.int Dr Yooni Oh, Regional Project Coordinator, OIE Regional Representation for Asia and the Pacific, Food Science Building 5F, The University of Tokyo, 1- 1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan, Telephone: +81 3 5805 1931, Email: y.oh@oie.int 4. OBSERVERS Dr Dennis Carroll, Director, Pandemic Influenza and other Threats, US Agency for International Development, 1300 Pennsylvania Ave, Washington, DC 20523, Telephone: 202 712 5009, Email: dcarroll@usaid.gov Ms Yuko Fukuda, British Embassy, Tokyo, Email: yuko.fukuda@fco.gov.uk Michiko Kawanishi, National Veterinary Assay Laboratory, Ministry of Agriculture, Forestry and Fisheries, Email: michiko_kawanishi@nval.maff.go.jp Dr Lawrence Kerr, Director, Pandemics and Emerging Threats, Office of Global Affairs, Health and Human Services Email: larry.kerr@hhs.gov Dr Kaname Kanai, Team Leader from Terminal Evaluation (TE), Japan International Cooperation Agency, Tokyo, Japan Michiko Kawanishi, Assay 2, National Veterinary Assay Laboratory, Ministry of Agriculture, Forestry and Fisheries, 1-15-1 Tokura Kokubunji, Tokyo 185-8511, Japan Dr Kenichi Komada, International Medical Cooperation Japan, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo 162-8655, Japan, Email: k-komada@it.ncgm.go.jp Dr Susumu Kunisawa, Senior Lecturer, Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, kunisawa.susumu.2v@kyoto-u.ac.jp Dr Ichiro Kurane, Director-General, National Institute of Infectious Diseases, Japan Mr Jun Moriyama, Bureau of International Cooperation, National Center for Global Health Medicine, 121 1, Toyama Shinjuku-ku, Tokyo, Japan, Telephone: 81 3 3202 7181, Email: j-moriyama@it.ncgm.go.jp Professor Hiroki Nakatani, Professor for Global Initiatives, Keio University Mr Yumiko Myoken, Senior Science and Innovation Officer, British Embassy, 1 Ichiban-cho, Chiyoda-ku, Tokyo, Japan, Email: Yumiko.Myoken@fco.gov.uk Ms Risa Nakayama, Consultant, World Bank Tokyo Office, Fukoku Seimei Building 10th Floor, Uchisaiwaicho 2-2-2, Chiyoda-ku, Tokyo, Japan Dr Norio Ohmagari, Director, Disease Control and Prevention, National Center for Global Health and Medicine Hospital, Ichigaya-Kagacho, Shinjuku-ku, Tokyo, Japan, Email: lukenorioom@gmail.com Dr Hisako Okura, Second Risk Assessment Division, Food Safety Commission of Japan, Cabinet Office, Government of Japan Dr Phusit Prakongsai, Director, Bureau of International Health, Office of the Permanent Secretary, Ministry of Public Health of Thailand, Email: phusit@ihpp.thaigov.net Ms Maria Lourdes Santiago, Director General, Food and Drug Administration Philippines, Civic Drive, Filinvest Corporate City, Alabang, Muntinlupa City, Philippines, Telephone: +632 857 1999, Email: mlcsantiago@fda.gov.ph Dr Suguru Sato, Ag Specialist, United States Department of Agriculture, Foreign Agricultural Service, 1-10-5 Akasaka, Minato-ku, Tokyo 107-8420, Japan, Email: suguru.sato@fas.usda.gov Dr Go Tanaka, Councellor, Coordination Office of Measures on Emerging Infectious Diseases, Cabinet Secretariat, Government of Japan Mr Kozo Watanabe, Director, Health Systems Division, Health Systems and Reproductive Health Group, Human Development Department, JICA Dr Koji Yahara, Senior Research Fellow, National Institute of Infectious Diseases, Email: koji.yahara@gmail.com Dr Kazuto Yamashita, Postdoctoral Fellow, Kyoto University 5. SECRETARIAT Dr Takeshi Kasai, Director, Programme Management, World Health Organization Regional Office for the Western Pacific, UN Avenue, 1000 Manila, Philippines, Telephone: +63 2 5289923, Email: kasait@wpro.who.int Dr Vivian Lin, Director, Division of Health Systems, World Health Organization Regional Office for the Western Pacific, UN Avenue, 1000 Manila, Philippines, Telephone: +63 2 5288902, Email: linv@who.int Dr Klara Tisocki, Coordinator, Essential Medicines and Health Technologies, World Health Organization Regional Office for the Western Pacific, UN Avenue, 1000 Manila, Philippines, Telephone: +63 2 5288906, Email: tisocki@who.int Dr Tomohiko Makino, Medical Officer, Country Support Unit, Partnership in Technical Cooperation, World Health Organization Regional Office for the Western Pacific, UN Avenue, 1000 Manila, Philippines, Telephone: +63 2 5288906, Email: makinoto@who.int Dr Sarah Paulin, Technical Officer, AMR, Essential Medicines and Health Technologies, World Health Organization Regional Office for the Western Pacific, UN Avenue, 1000 Manila, Philippines, 1000 Manila, Philippines, Telephone: +63 2 5288946, Email: paulins@who.int Dr Arun Bhadra Thapa, Director, Programme Management, World Health Organization Regional Office for the South-east Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi, India, Tel. No.: +911123370804, Email: thapaa@who.int Dr Roderico Ofrin, Director, Department of Health Security and Emergency Response, World Health Organization Regional Office for the South-east Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi, India, Telephone: +911143040444, Email: ofrinr@who.int Professor Tjandra Aditama, Regional Coordinator, Department of Health Security and Emergency Response, World Health Organization Regional Office for the South-east Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi, India, Telephone: +911123309412, Email: aditamat@who.int Dr Keiji Fukuda, Special Representative of the, WHO Director General, World Health Organization, Avenue Appia 20, CH-1211, Geneva, Switzerland, Telephone: +41 22 791 3871, Email: fukudak@who.int Ms Yuki Minato, Technical Officer, Food Safety, Zoonoses and Foodborne Diseases, World Health Organization, Avenue Appia 20, CH-1211, Geneva, Switzerland, Telephone: +41 22 791 3713, Email: minatoy@who.int Annex 2. Programme of Activities Day 1. 14 April 2016 7:30 – 8:30 Registration 8:30 - 9:00 Opening session – Plenary Welcome messages Dr. Vivian Lin, WHO, on behalf of SEARO and WPRO Regional Directors Dr. Masato Kasuga, President, National Center for Global Health and Medicine, Japan Introductions Objectives of the meeting - Dr. Klara Tisocki, WHO Election of chairpersons (2) and rapporteurs (2) 9:00- 10:00 Session 1 – Plenary: The Threat of Antimicrobial Resistance A ticking time bomb: the health threat of antimicrobial resistance - Dr Dame Sally Davies, Chief Medical Officer, United Kingdom Antimicrobial resistance: a human health security threat requiring global and regional actions - Dr Keiji Fukuda, WHO Antimicrobial resistance: threat to food security - Dr Katinka de Balogh, FAO Challenges of Antimicrobial resistance in Asian livestock - Dr. Mary Joy N. Gordoncillo, OIE Animals & antibiotics: Risks to humans - Dr Tetsuo Asai, Japan 10:00- 10:15 Session 2 – Plenary: Actions to Contain Antimicrobial Resistance in Asia Pacific• Presentation of draft Ministerial Statement on Antimicrobial Resistance - Dr Yasuhiro Suzuki, Japan Action Framework for implementing the Ministerial Statement - Dr. Vivian Lin, WHO 10:15- 10:40 Group photo - Coffee Break 10:40 - 11:20 Session 3 – Panel discussion: Advancing Awareness Raising: Target Groups and Messages Moderator: Dr. Otto Cars, Sweden Introductory Presentations (5 min): Stopping AMR is everybody’s business -Dr. Visanu Thamlikitkul, Mahidol University Panel topic: Advocacy through annual Antibiotic Awareness Week Panel members: MOH China, MOH India, MOH Malaysia, MOH Viet Nam 11:20- 12:15 Session 4 - Panel discussion: Slowing Down Antimicrobial Resistance through Stronger Health Systems – The Role of Universal Health Coverage (UHC) Moderator : Dame Sally Davies Introductory presentations (5 min): Towards an integrated approach to AMR and UHC - Dr Vivian Lin, WHO National health systems and governance of AMR - Dr Ramon Shaban, Australia Panel topic: Addressing AMR by progressing with UHC Panel Members: MOH India, MOH Philippines, MOH Myanmar, MOH Rep. Korea 12:15-13:15 Lunch 13:15-14:30 Session 5 - Panel discussion: Fighting Antimicrobial Resistance – A Key Action for Reaching Sustainable Development Goals Moderator: Dr Roderico Ofrin, WHO Introductory presentation (10 min): No sustainable development without antibiotics - Professor Otto Cars, Sweden Panel topic: AMR as a development agenda requiring national governance for a multi-sectoral approach Panel Members: MOA China, MOA Japan, MOA Indonesia, MOH Bangladesh, FAO, OIE 14:30 -15:00 Coffee break 15:00-16:30 Plenary discussions Moderators: Dame Sally Davies, Dr. Otto Cars and Dr. Roderico Ofrin Question/ Answer/ comments on Panel discussions Reflections by moderators on key messages and actions from Panel discussions (Sess. 3-5) Summary of Day 1 – Dame Sally Davies 16:30 End of Day 1 DAY 2. 15 April, 2016 8:30- 8:40 Recap of Day 1 Dr Vivian Lin, WPRO 8:40-10:00 Session 6 – Plenary: Governance for Multisectoral National Plans for Containment of Antimicrobial Resistance Introductory presentation (10 min): AMR as regional health security challenge requiring urgent national action – Dr. Haruo Watanabe, Japan Reflections on governance of AMR – National mechanisms, challenges and next steps for development and implementation of national action plans (10 min/ country including questions): - Australia - Bangladesh - China - India - Indonesia - Japan 10:00-10:30 Coffee break 10:30-11:30 Session 6 continued – Plenary: Governance for Multisectoral National Plans for Containment of Antimicrobial Resistance Country presentations - Reflections on governance of AMR – National mechanisms, challenges and next steps for implementation of national action plans (10 min/ country including questions) - Malaysia - Myanmar - Philippines - Republic of Korea - Thailand - Viet Nam 11:30-12:15 Session 7 - Plenary: Monitoring the Implementation of National Action Plans on AMR Introductory presentation (15 min): Monitoring and evaluation approaches to measure results and progress on tackling antimicrobial resistance - Dr Keiji Fukuda, WHO Plenary discussion: How should we measure national and regional progress? 12:15-13:00 Lunch 13:00-13:45 Session 8: Panel discussions: Opportunities in Asia Pacific Region to Contribute to the Global Response to Antimicrobial Resistance Moderator: Dr. Takeshi Kasai, WPRO Panel 1: Surveillance and data sharing across regions and globally Introductory Presentation (10 min): Importance of robust surveillance systems across Asia - Dr Keigo Shibayama, National Institute of Infectious Diseases, Japan Panel members: MOH Japan, MOH Australia, MOH Myanmar, MOH Philippines, ADB 13:45-14:30 Panel 2: Research and development (R&D) of new diagnostics and antimicrobials – regional capacities and potential regional mechanisms to stimulate R&D Introductory Presentation (5 min) Asia Pacific capacities for development of new technologies to control AMR - Dr. Junko Sato, Japan Panel members: MOH China, MOH Japan, MOH Rep. Korea, MOH Thailand 14:30-14:45 Coffee break 14:45-15:45 Session 9: Plenary Review of the meeting summary and recommendations Adoption of meeting summary and recommendations 15:45 - 16:00 Closure of the workshop - Summary remarks Professor Otto Cars, Dr Arun Thapa, WHO 18:00 – 20:00 Reception – Orion Room, 2F, Josui Kaikan End of Meeting Annex 1. Presentations 14 April 2016 1 A ticking time bomb: The threat of antimicrobial resistance Professor Dame Sally C Davies, FRS Chief Medical Officer for England 2 It is not difficult to make microbes resistant to penicillin in the laboratory, and the same has occasionally happened in the body. Alexander Fleming, 1945 Nobel Prize Acceptance Speech 3 A brief history of antibiotic resistance Discovery void No new class of antibiotics has been discovered since 1987 Pe ni cil lin s 19 28 Ce ph al os po rin s 19 48 Su lp ho na m id es 19 32 Am in og lyc os id es , Ba cit ra cin 19 43 Te tra cy cli ne s 19 45 N itr of ur an s 19 46 Pl eu ro m ut ilin s 19 50 M ac ro lid es 19 52 G lyc op ep tid es , N itr oi m id az ol es , St re pt og ra m in s 19 53 Cy clo se re ne , N ov ob io cin 19 55 R ifa m yc in s 19 57 Po lym yx in s, Ph en ico ls 19 47 Fo sf om yc in 19 69 Tr im et ho pr im 19 61 Qu in ol on es , Li nc os am id es , Fu sid ic ac id 19 62 M up iro cin 19 71 Ca rb op en em s 19 76 O xa zo lid in on es 19 78 M on ob ac ta m s 19 79 Li po pe pt id es 19 87 1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s 2010s Based on discovery void image from World Economic Forum “Global Risks 2013” http://www3.weforum.org/docs/WEF_GlobalRisks_Report_2013.pdf 4 Epidemiology of AMR Diagram based on Linton (1977), as adapted by Rebecca Irwin, Health Canada (Prescott 2000) and IFT Soil WILDLIFE Irrigation water Farm effluents & manure spreading OffalRendering Dead stock FOOD ANIMALS Industrial & household antimicrobial chemicals Food processing antimicrobials Sewage AQUACULTURE HUMANSHandling,preparation, consumption Commercial abattoirs & processing plants COMPANION ANIMALS Direct contact 5 Percentage Change in Antibiotic Consumption per capita 2000-2010 Source: CDDEP – The state of the World’s Antibiotics 2015 6 How Much Could AMR Cost the World in Mortality? Source: Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations – The Review on Antimicrobial Resistance Chaired by Jim O’Neill 14 April 2016 7 8 There are Significant Gaps in Global Surveillance, 2014
Many countries are reporting AMR data on less than 5/9 WHO microbes of international concern.
Some of best data on AMR is from disease-specific programmes (e.g. TB). 9 What Must Governments Do? • Among the public, patients and medical and animal care professionals. Awareness • ‘Access, not excess’ • Infection prevention and control • Improved surveillance Conservation • New antimicrobials • New rapid diagnostic tests Innovation 10 Fleming Fund New £265 million UK Government commitment over 5 years Aims: • Strengthen antimicrobial surveillance - with particular focus on laboratory capacity and diagnosis in low-income countries • Support policy makers in translating good surveillance data into action • Support collaborative efforts to implement - the WHO global action plan - Global Health Security Agenda 11 Review on AMR – areas for action: Actions are focussed on reducing human and animal demand for antibiotics or increasing the supply of useful products: 1. A massive global public awareness campaign 2. Improve handwashing and prevent the spread of infection 3. Reduce unnecessary antibiotic use in agriculture 4. Use vaccines more, new and existing, for humans and animals 5. Improve global surveillance, for humans and animals 6. Promote new, rapid diagnostics to cut unnecessary use of antibiotics 7. Improve the numbers and pay of those researching AMR 8. Provide market incentives to support private investment in effective antibiotics (using new and old molecules) 9. Establish a global innovation fund for early-stage research and improving existing drugs 10. Build a global coalition for real action – particularly via the G20 12 Principles for the Review Recommendations: As a key part of the wider package, Jim O’Neill will set out clear proposals for action to stimulate the antibiotics pipeline: • A new global payer mechanism to coordinate efforts to stimulate and incentivise antibiotic R&D internationally • This would offer market entry rewards – lump sum payments (some of $1bn or more) to the developers of new antibiotics that meet specified unmet medial needs. • The system will help ‘de-link’ the profitability of an antibiotic from the volume sold – supporting stewardship and providing certainty for developers. Similar support mechanisms will also need to extent to vaccines, diagnostics, and alternatives to conventional antibiotics – all of which face some degree of market failure but which are vital parts of battle against AMR. The Review will also propose how such a global system can be funded; and how it can support affordable global access to antibiotics 14 April 2016 13 UNGA Road Map January • Davos Pharma Declaration • WHO Exec Board February • Indian AMR Conclave April • Bi-regional technical consultation on AMR - Japan • Asian Health Ministers on AMR – Japan • Wellcome Trust Science Summit May • One Health Global Summit- London • WHA • G7 Leaders summit • O’Neill report published September • G20 Leaders Meeting • G7 Health Ministers • UNGA Ministerial Week 14 An ambitious outcome from UNGA • UNGA is an opportunity to accelerate implementation of the Global Action Plan with potential focus on the following areas: • Renewed vigour for Member states developing National AMR-Action Plans by 2017, stressing the need for multisectoral involvement and with support from the relevant UN agencies where needed. • Rectifying gaps in surveillance identified in the Global Action Plan, including defining standards for reporting on antimicrobial resistance in human health and harmonising national programmes for monitoring antimicrobial resistance in animal health, enabling countries to move towards setting targets / limits on use. • Regulating the sale and use of antibiotics and antimicrobials, including over-the- counter and internet sales, and ensuring that these regimes are enforced. • Working towards phasing out use of antibiotics that are medically important, or likely to drive resistance to antibiotics that are medically important, for growth promotion in agriculture. Also invest research into economic benefits of alternative methods of animal husbandry and plant production which reduces the need for antibiotics Enter the presentation's title using the menu option View > Header and Footer 15 Public information and education Antimicrobial Resistance - a threat to humanity http://bit.ly/CMOatTEDxhttp://bit.ly/CMObook 14 April 2016 Responding to AMR Bi-regional Technical Consultation on Antimicrobial Resistance (AMR) in Asia Tokyo, 14 April 2016 Keiji Fukuda, April 20162 | AMR is complex !
Many microbes & antimicrobials with continuously evolving resistance patterns & variations
Drivers include cultural norms, financial incentives, inequity
Major aspects include global / multisectoral scope, critical technical details, culture, politics, commercial, development
Low awareness or “ownership” among key groups
No single “face,” no simple message, no natural home
Easy to slip into “blame game” & traditional divisions April 20163 | Many preceding response efforts
Scientific & technical studies & guidelines
National, regional, global initiatives – WHO WG in 1959
Awareness raising days & campaigns April 20164 | But we are not winning
WHO survey of 114 countries
All regions: very high resistance in common bacteria to key antibiotics – E coli, K pneumoniae, S aureus, S pneumoniae, N gonorrhea …. – 3rd generation cephalosporins, fluoroquinolones, methicillin …..
Under reporting of major infections like MDR TB April 20165 | Status quo or giving up is not an option April 20166 | How will we succeed?
Continue building scientific - technical foundation – Knowledge, technologies, effective practices ….
Create political support to enable action – Established mechanisms: G7, G20, G77, UNGA ….. – Financing, intersectoral coordination, legislation …
Unleash ownership & socialization for sustainability – Best practices across sectors: health, food, agriculture, industry, development, individuals, families, communities, organizations 14 April 2016 April 20167 | 2016 is pivotal
Simultaneous technical, political, social progress
Global action plan available covering what to do
UN GA & associated meetings provide roadmap to gain & focus political support
Socialization & ownership becoming visible April 20168 | Ownership & socialization Reported in Reuters (Apr 2016): Investor group launches campaign to curb antibiotic use in food
54 large investors managing 1 trillion pounds ($1.41 trillion) in assets
Have launched a campaign to curb use of antibiotics in meat & poultry
Focus on 10 large U.S. & British restaurant groups April 20169 | Ownership & socialization
Uncontrolled but essential element for change (tobacco control, climate change, etc)
Potential to shape, drive & sustain future directions
Underway April 201610 | Global Action Plan on Antimicrobial Resistance
Adopted by World Health Assembly in 2015
Recognized & supported by FAO (Resolution 4/2015) and OIE (Resolution 26) governing bodies in 2015 April 201611 | AMR Global Action Plan
Foundation built on consultation, collaboration, consensus – Countries, FAO, OIE, civil society & other stakeholders – Global scientific expertise & experience
Consensus global technical blueprint for next 5-10 years
Guidance for national planning April 201612 | Emphases of GAP
Whole-of-society / one-health approach
Prevention first
Equitable access & appropriate use of antimicrobial medicines
Sustainability
Incremental targets, stepwise implementation 14 April 2016 April 201613 | Five strategic objectives 1. Improve awareness and understanding 2. Strengthen knowledge through surveillance & research 3. Reduce incidence of infection 4. Optimize use of antimicrobial medicines 5. Ensure sustainable investment April 201614 | National Action Plans
Call by WHA or national plans to be ready by 2017
Most essential element is national dialogue involving all key stakeholders
Greatest current challenge is achieving strong intersectoral engagement & consensus April 201615 | Political engagement
Missing from previous decades of work
High Level Meeting planned for UNGA (Sept 2016) marks major political step forward – But one step in longer process – Cannot address all needs
Post UNGA processes needed to find sustainable solutions to specific pressing issues – Stewardship, R&D, access, financing, food …… April 201616 | Concluding Observations
Challenges are vast but must be “won” because consequences are unacceptable
Progress in all critical areas - technical, political, social – can leap further in 2016 with sufficient focus & work
For countries - development & implementation of national action plans is most critical next action April 201617 | Thank you 14 April 2016 Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Antimicrobial Resistance (AMR) A Threat to Food Security Dr. Katinka de Balogh Senior Officer-Animal Health and Production Food and Agriculture Organization of the United Nations Regional Office for Asia and the Pacific katinka.debalogh@fao.org Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Food and Agriculture Organization of the United Nations Mandate: to build a world without hunger Consumption of animal source foods is growing rapidly compared to cereals, roots and tubers… Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan 10 0 20 0 30 0 40 0 50 0 In de x n u m be r: 19 61 = 10 0 1960 1970 1980 1990 2000 2010 Roots and tubers Cereals Meat Milk Eggs Eggs Meat Milk Cereals Roots and tubers Source: FAO SOFA 2009 Global production of aquatic organisms in million tonnes, since 1950, as reported by the FAO Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Global production of aquatic organisms in million tonnes, since 1950 Source: FAO statistics Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Megacities 14 April 2016 . Population growth and urbanization The rapid growth of cities is placing enormous demands on (urban) food supply systems. Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Meat production is growing, but with striking regional differences ... Meat production is growing, but with striking regional differences ... Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan 0 20 40 60 80 10 0 M illi on to n n es 1960 1970 1980 1990 2000 2010 East and Southeast asia Latin America and Caribbean Near East and North Africa South Asia Sub-Saharan Africa East and Southeast Asia Source: FAO SOFA 2009 Latin America and Caribbean Source: FAO Stat Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Source; FAO Stat Antimicrobial Use Data availability? Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Risk of contamination and/or cross-contamination of food with AMR organism Antimicrobial resistant micro-organisms can spread through the food chain and the environment Antimicrobial use Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Antimicrobial resistant micro-organisms can spread through the food chain and the environment 14 April 2016 Promote good practices and the prudent use of antimicrobials Trusted agriculture extension and animal health services are key!! Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan FAO calls for cross-sectoral action and public-private partnerships Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Animal health Food safety alimentarius Plant FisheriesLegal Regional and sub- regional offices National offices Livestock FAO Action Plan on AMR Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan The 39th Session of FAO's governing Conference in June 2015 Adoption of the Resolution 4/2015 on AMR Need for a cross-sectoral and multidisciplinary OneHealth approach: FAO focus-areas for action Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan 1. Improve awareness and advocacy on AMR and related threats 2. Develop capacity for surveillance and monitoring of AMR and AMU in food and agriculture 3. Strengthen governance related to AMU in food and agriculture 4. Promote good practices in food and agricultural systems and the prudent use of antimicrobials AMR Multi-stakeholder workshop, 16 March 2016, Harare, Zimbabwe AMR Multi-stakeholder workshop, 16 March 2016, Harare, Zimbabwe 14 April 2016 Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan Thank you! Technical Consultation on AMR in Asia 14-15 April, Tokyo, Japan katinka.debalogh@fao.org 14 April 2016 Mary Joy Gordoncillo, DVM, MTVSc, PhD Challenges in addressing AMR in Asian Livestock and relevant OIE activities Bi-regional Technical Consultation on Antimicrobial Resistance in Asia 14-15 April 2016 * Tokyo, Japan Science and One Health Coordinator Current situation and challenges World Organisation for Animal Health · Protecting animals, Preserving our future | 3 Antimicrobials are a precious necessity for animal health and welfare and public health, but currently: • No control of antimicrobial agent circulation in more than 100 countries • Falsified product make up a majority of circulating antimicrobials • Challenge in many countries: unrestricted access to antimicrobials by farmers without veterinary oversight The situation today World Organisation for Animal Health · Protecting animals, Preserving our future | 4 Legislation covering Veterinary Medicinal Products (2012) OIE survey on quantities of antimicrobial agents used in animals, 2012 World Organisation for Animal Health · Protecting animals, Preserving our future | 5 Yes; 41; 27% No; 111; 73% Official system for collecting quantitative data (2012) OIE survey on quantities of antimicrobial agents used in animals, 2012 World Organisation for Animal Health · Protecting animals, Preserving our future | 6 Plans to set up official quantitative data collection (2012) 65 % 96% OIE survey on quantities of antimicrobial agents used in animals, 2012 14 April 2016 World Organisation for Animal Health · Protecting animals, Preserving our future | 7 AMR surveillance, usage, and reference laboratories 5/21 (23.8%) 16/21 (76.2 %) With identified institutions involved in AMR surveillance in animal Health without 16/21 (76.2 %) 5/21 (23.8 %) With identified agencies involved in monitoring AMR usage in animal health without 6th Asia-Pacific Workshop on Multi-Sectoral Collaboration on Prevention and Control of Zoonoses, 2015 (n=21) 8/21 (38.1%) 4/21 (19.0%) 9/21 (42.9 %) No information With national AMR reference laboratories for animas without World Organisation for Animal Health · Protecting animals, Preserving our future | 8 Political engagement on AMR mitigation 6th Asia-Pacific Workshop on Multi-Sectoral Collaboration on Prevention and Control of Zoonoses, 2015 (n=21) World Organisation for Animal Health · Protecting animals, Preserving our future | 9 “What are the most critical gaps on AMR mitigation in your country?” 6th Asia-Pacific Workshop on Multi-Sectoral Collaboration on Prevention and Control of Zoonoses, 2015 (n=21) Awareness on antimicrobial use Awareness on AMR Awareness on compliance Information to support policies Human resource Laboratory capacity No AMR surveillance Research and developmentStandards for monitoring Infection control practice Guidelines Overuse and misuse Rampant use of higher generation antibiotics No monitoring of AMU Lack of oversight of circulating animal drugs Control on distributions Enforcement on misuse by non- vets Regulation of OTC sales Pharmacovigilance Policy to deal with AMR No national strategy/plan Law enforcemen t Legal framework Lack of secondary legislations Implementatio n at the local level Lack of programmes National priority FUNDING World Organisation for Animal Health · Protecting animals, Preserving our future | 10 IMPROVE AWARENESS Awareness on antimicrobial use Awareness on AMR Awareness on compliance Information to support policies STRENGTHEN SURVEILLANCE & RESEARCH SANITATION, HYGIENE & INFECTION PREVENTION OPTIMI ZE ANTIMIC ROBIAL USE ADVOCATE FOR SUSTAINABLE INVESTMENT Human resource Laborator y capacity No AMR surveillanc e Research and development Standards for monitoring “What are the most critical gaps on AMR mitigation in your country?” 6th Asia-Pacific Workshop on Multi-Sectoral Collaboration on Prevention and Control of Zoonoses, 2015 (n=21) Infection control practice Guidelines Infection prevention and control Overuse and misuse Rampant use of higher generation antibiotics No monitoring of AMU Lack of oversight of circulating animal drugs Control on distributions Enforcement on misuse by non-vets FUNDIND No national strategy/plan Law enforcement Legal framewor k Lack of secondary legislations National priority Multisectoral collaboration – a successful plan against AMR is inherently interdependent - (including coordination of effective policies; legislation on access to, and restricted use of, quality drugs; and R&D of new drugs) Standard s Capacity building Collabo- ration Data Country support International standards (to harmonise protocols and methodologies) - to monitor AMR and antimicrobial usage, and good governance of all sectors related to authorisation and use of antimicrobials Building of technical capacity – to conduct surveillance of AMR and antimicrobial use, and AMR risk analysis Information collection and sharing - monitoring and surveillance data on AMR and antimicrobial use, and AMR risk analysis Support to countries - to successfully plan and implement national AMR strategies Needs OIE Activities to tackle Antimicrobial Resistance 14 April 2016 World Organisation for Animal Health · Protecting animals, Preserving our future | 13 OIE (World Organisation for Animal Health) WORLD ASSEMBLY OF DELEGATES: The highest authority of the OIE. One OIE Delegate All Delegates worldwide meet once a year (General Session) OIE National Focal Points • Animal disease notification • Animal production and food safety • Animal welfare • Aquatic animals • Communication • Laboratory • Veterinary Products • Wildlife 1 country = 1 vote In each of the 180 Member Countries: OIE is an intergovernmental organisation responsible for improving animal health worldwide. World Organisation for Animal Health · Protecting animals, Preserving our future | 14 83rd General Session in May 2015 Resolution No. 26 “Combating Antimicrobial Resistance and Promoting Prudent Use of Antimicrobial Agents in Animals” • Tripartite collaboration • Support to Global Action Plan • Support to development of National Action Plans • Collaboration with Public Health officials • Support to Global database on AMU in animals • Improvement on veterinary legislation • Improvement of AMR inclusion in Vet education • Others (Adopted by the World Assembly of Delegates of the OIE on 26 May 2015 in view of an entry into force on 30 May 2015) World Organisation for Animal Health · Protecting animals, Preserving our future | 15 UPDATES OF OIE STANDARDS OIE GLOBAL DATABASE ON AMU IN ANIMALS OIE LIST OF ANTIMICROBIALS PVS PATHWAY AND LEGISLATION MISSIONS VETERINARY EDUCATION AND VET STATUTORY BODIES OIE NATIONAL FOCAL POINTS SYSTEM QUALITY OF VETERINARY SERVICES AND LABORATORIES OIE ACTIVITIES ADDRESSING ANTIMICROBIAL RESISTANCE IN ANIMALS World Organisation for Animal Health · Protecting animals, Preserving our future | 16 UPDATES ON OIE STANDARDS & GUIDELINES • Updated and adopted between 2012 and 2015 • WHO and FAO participate in the ad hoc Group on AMR • http://www.oie.int/en/international-standard-setting/terrestrial- code/access-online/ World Organisation for Animal Health · Protecting animals, Preserving our future | 17 OIE LIST OF ANTIMICROBIAL AGENTS OIE List of Antimicrobial Agents of Veterinary Importance: • updated in 2014 • to take into account concerns for human health • (WHO and FAO participated in this task) Recommendation: Any use of antimicrobial agents in animals should be in accordance with OIE standards on responsible and prudent use World Organisation for Animal Health · Protecting animals, Preserving our future | 18 OIE GLOBAL DATABASE ON AMU IN ANIMALS 1 • A system where all can contribute 2 • That safeguards information 3 • That is pragmatic regarding the data collected 4 • That will help to get comparable data • Part of Global Action Plan on AMR and endorsed by the OIE Delegates (Resolution 26) • Feedback to the OIE World Assembly: May 2016 14 April 2016 World Organisation for Animal Health · Protecting animals, Preserving our future | 19 OIE GLOBAL DATABASE ON AMU IN ANIMALS 79.6 65.5 71.9 67.9 41.7 AFRICA AMERICA ASIA EUROPE MIDDLE EAST Proportion of OIE Member Countries submitting questionnaires by OIE Regions(Preliminary results - as of 13 04 2016) PVS PATHWAY AND LEGISLATION MISSIONS VETERINARY EDUCATION SPECIFIC COMPETENCIES FOR DAY 1 GRADUATES: • Epidemiology • Transboundary animal diseases • Zoonoses (including food borne diseases) • Emerging and re-emerging diseases • Disease prevention and control programmes • Food hygiene • Veterinary products • Animal welfare • Veterinary legislation and ethics • General certification procedures • Communication skills World Organisation for Animal Health · Protecting animals, Preserving our future | 22 WORLD ASSEMBLY OF DELEGATES: The highest authority of the OIE. One OIE Delegate All Delegates worldwide meet once a year (General Session) OIE National Focal Points • Animal disease notification • Animal production and food safety • Animal welfare • Aquatic animals • Communication • Laboratory • Veterinary Products (started in 2009) • Wildlife 1 country = 1 vote In each of the 180 Member Countries: OIE NATIONAL FOCAL POINTS SYSTEM Regional capacity building workshop for National Focal Points for Veterinary Products in all regions OTHER RELATED INITIATIVES at OIE Headquarters • 2012 – First International Symposium on Alternatives to Antibiotics • December 2016 – Second International Symposium on Alternatives to Antibiotics OTHER RELATED INITIATIVES Antibiotic Awareness Week Access the WHO page dedicated to World Awareness Week 2015 http://www.oie.int/es/para-los-periodistas/amr-es/related-links-es/ http://www.oie.int/en/for-the-media/amr/waaw2015/ 14 April 2016 ANTIMICROBIAL RESISTANCE (AMR): – http://www.oie.int/en/our-scientific-expertise/veterinary-products/antimicrobials/ – http://www.oie.int/en/for-the-media/amr/multimedia-ressources/ OTHER RELATED INITIATIVES 1. Collabora- tion 2. Standards 3. Capacity building 4. Information collection & sharing 5. Supporting Member Countries One Health Summary The One Health Collaboration Thank you for your attention 12, rue de Prony, 75017 Paris, France www.oie.int media@oie.int - oie@oie.int 14 April 2016 1 Animals & antibiotics: Risks to humans Tetsuo Asai United Graduate School of Veterinary Medicine, Gifu University The use of antimicrobials Antimicrobial Resistance (AMR) Antimicrobials Essential for health and welfare in animals as well as humans. Can be linked to emergence or prevalence of resistant bacteria. Possibly
Transmit to humans via food chains.
Reduce the efficacy of antimicrobial therapy in humans and animals.  Risk Analysis of antimicrobial resistance  Responsible and Prudent Use of antimicrobials  Collection of information (Monitoring, Surveillance) To control AMR Use of antimicrobials Vancomycin, Rifampicin Penicillin, Cephalosporin Quinolone, Fluoroquinolone Aminoglycoside Macrolide, Colistin Tetracycline, Sulfonamide Streptogramin Ionophore Bicozamycin Medicine Veterinary medicine Feed additives Cabinet Office Governmental Structure to ensure Food Safety in Japan Consumer Affairs Agency Food Safety Commission (FSC) MAFF MHLW Consumers, Producers, Manufactures, etc. Notify Risk Assessment Recommendation Request Risk Assessment Notify Risk Assessment Recommendation Coordinate Risk Communication Risk analysis of Antimicrobial resistance in food-producing animals • 1999：Monitoring started by JVARM (Japanese Veterinary Antimicrobial Resistance Monitoring) • 2003：Request for risk assessment of Veterinary Antimicrobial Products and antimicrobial feed additives • 2012：Guideline for Establishment of Risk Management of Veterinary Antimicrobial Products • 2013：Establishment of Prudent Use Guideline • 2003：Established • 2004：Development of guideline for the assessment of the risk of selection of antimicrobial resistant bacteria by the use of antimicrobials in livestock production. • 2006 First assessment (Monensin) • 2010: Fluoroquinolone drug (cattle and pigs) : Medium • 2012: Tulathromycin (pigs)：Medium • 2013: Pirlimycin (Daily cow)：Low • 2013: Fluoroquinolone drug (poultry) : Medium 1999 2003 2010 JMAFFFSC 5 Guideline for Establishment of Risk Management of Veterinary Antimicrobial Products 6 First step: Selection of risk management options - on the basis of extent of the results of risk assessment by FSC (“high,” “medium,” “low,” or “negligible”) - according to examples of risk management Secondary step: Adoption of risk management options - considering the decision factors Decision factors Comments Significance of AVMPs in veterinary medicine Severity of the target disease Significance in the clinical settings The presence of alternates for the target disease Availability of alternates including different classes of antimicrobials and vaccines used for the same purposes Secondary risk Possible harmful consequences entailed in implementing each risk management option Estimated efficacy of risk management option Extent of efficacy imposed by implementing each risk management option Feasibility of risk management option Feasibility in terms of technical, administrative, and financial issues involved in implementing each risk management option Other concerns Decision factors depending on antimicrobial characteristics whenever necessary Assessment Result Examples of risk management options High Withdrawal Temporary ban on use High/ Medium Withdrawal of the antimicrobial - against specific animal species - against target disease/bacteria Limitation of antimicrobial use near the time of slaughter Shortening duration of antimicrobial administration Medium Strict use as secondary line of AVMPs Intensified monitoring of antimicrobial resistance Low/ Negligible Continued monitoring of antimicrobial resistance 14 April 2016 Prudent Use Guidelines “Prudent Use Guidelines” were established in 2013 and distributed to promote prudent use of antimicrobials Brochures explaining prudent use guideline for vets and livestock farmers. Livestock FarmerVet Sales of Antimicrobial Resistance in animal pathogens Healthy animals ○☆製薬 JVARM：Japanese Veterinary Antimicrobial Resistance Monitoring System Pharmaceutical companies Resistance in Zoonotic and Indicator bacteria Diseased animals The Sales of Antimicrobials for animals ( including food producing animals and companion animals) Polyethers Polyethers Veterinary Drugs Feed Additives 235 t 796 t Total 1292 t Total 1031 t 2001 2013 Monitoring of the quantities of antimicrobials used in animal husbandry estimated on the basis of sales/production quantities. 1059 t 233 t  MAFF ・Design risk managements and provide the data for risk assessments to FSC  NVAL（National Veterinary Assay Laboratory）  FAMIC（Food and Agricultural Materials Inspection Center） ・analyze, and evaluate data ・Research into molecular epidemiology, resistance mechanism  Prefectural livestock Hygiene Service Center （170 centers） ・Collect feces in farm, isolate and identify bacteria, and measure MIC  Farms Resistance Monitoring System（JVARM） Monitoring antimicrobial resistant bacteria since 1999 in the Japanese Veterinary Antimicrobial Resistance Monitoring System (JVARM)  Target bacteria: Indicator (Escherichia coli, Enterococcus spp.), Zoonotic bacteria (Salmonella spp., Campylobacter spp.) JVARM Report Report Isolated bacteria, Data Samples JVARM has started collaboration with JANIS (Japan Nosocomial Infectious Surveillance: AMR surveillance for human health sector) in order to establish the integrated surveillance system recommended by WHO based on One Health Approach. MAFF has added the monitoring of samples collected from slaughterhouses since 2012. E. coli Fluoroquinolone LVFX ERFX CPFX Pig Cattle BroilerLayer Enrofloxacin Ciplofloxacin Levofloxacin JANIS ：Resistance rates have increased by about 3 times in 10 years JVARM :Resistance rates have not increased since 2003 12 The resistance rate of cephalosporin in E. coli isolates from healthy broilers Hiki M et al. Foodborne Pathog Dis. 2015 Jul;12(7):639-43. 14 April 2016 0% 5% 10% 15% 20% 25% 30% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Cefazolin (CEZ) First-generation cephalosporins 採卵鶏 豚 肉用牛 肉用鶏 JANISLayer Pig Cattle Broiler Significance of Nationwide Monitoring • To Understand the baseline of antimicrobial resistance prevalence in bacteria • To compare the data between humans and animals • To provide data for the risk assessment 14 • To take the interest in the antimicrobial resistance in animals • To improve the lab technique concerning antimicrobial resistance Prefectural Livestock Hygiene Service Center Aquatic NVAL ・AMR central lab ・ＯＩＥ collaborating center Human sector MAFF Livestock hygiene service centers Private test service Livestock insurance system Aquatic test facilitiesAcademia Animal hospitals Livestock Other Asian member states International contribution Pet Environment 15 JVARM JANIS Future tasks 16  Further improvement of the awareness of Prudent use of Veterinary antimicrobials • Control of the infectious disease through appropriate management of feeding, sanitation and vaccines. • Enlightenment activity of government for promoting the prudent use to Clinical veterinarian and food-animal producers  Enforcement of One Health surveillance on antimicrobial resistance • Development of collaborative approach or integrated national surveillance and monitoring program between humans and animals • Comparison of the data between human and animal section using molecular and/or genome analysis Thank you for your attention! 14 April 2016 Stopping AMR is Everybody’s Business Professor Visanu Thamlikitkul, MD Thailand AMR Containment and Prevention Program (f) WHO CC for Prevention and Containment of AMR Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Thailand AMR Program Journal of Global Antimicrobial Resistance 2015;3:290-4. Awareness and Understanding of AMR Thailand AMR Containment and Prevention Program 2013-2016 • AMR Chain in Community in Thailand Thailand AMR Containment and Prevention Program 2013-2016 • AMR Chain in Hospital in Thailand Infection Prevention & Control (IPC) 14 April 2016 AMR affects all citizens • No matter who you are, you are at risk of being colonized and/or infected with AMR bacteria • AMR matters everybody AMR chain in community AMR chain in hospital Thailand AMR Containment and Prevention Program 2013-2016 IPC Thailand AMR Containment and Prevention Program 2013-2016 How people know/are aware about AMR • 4 pilot communities of 2 provinces with population of 400,000 • Survey 28,000 people, most of them
have never heard of AMR
do not believe that AMR is real
are not afraid of AMR
will not get AMR infection
are not involved in producing or spreading of AMR Thailand AMR Containment and Prevention Program 2013-2016 What are found from field studies in these communities • 41% of 215 grocery stores & retail shops illegally sell antibiotics • 45 drug stores & private clinics dispense/prescribe antibiotics in 75% of ailments that do not require antibiotics • ESBL-producing E.coli is isolated from 26% of 174 samples of food and environment • ESBL-producing E.coli is isolated from 66% of 534 stool samples of healthy individuals Thailand AMR Containment and Prevention Program 2013-2016 How people know/are aware about AMR • 4 pilot communities of 2 provinces with population of 400,000 • Survey 28,000 people, most of them
have never heard of AMR
do not believe that AMR is real
are not afraid of AMR
will not get AMR infection
are not involved in producing or spreading of AMR People in these communities are not aware of and do not understand AMR Logo: Thai Logo : English Thailand AMR Containment and Prevention Program 2013-2016 Logo and Slogan of AMR Core Campaign Slogan : Stopping AMR is Everybody’s Business 14 April 2016 Thailand AMR Containment and Prevention Program 2013-2016 AMR Core Campaign Thailand AMR Containment and Prevention Program 2013-2016 AMR Core Campaign Infection Prevention & Control (IPC) Slogan : Stopping AMR is Everybody’s Business Thailand AMR Containment and Prevention Program 2013-2016 AMR Core Campaign Thailand AMR Containment and Prevention Program 2013-2016 AMR Campaign in Community at Household Level 8,000 Trained Village Health Volunteers 400,000 people in 120,000 households Stopping AMR is Everybody’s Business Professor Visanu Thamlikitkul, MD Thailand AMR Containment and Prevention Program (f) WHO CC for Prevention and Containment of AMR Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Thailand AMR Program 14 April 2016 Levels of awareness of the issue of antibiotic resistance and levels of understanding around the issue and how to address it • 57% state that there is not much that people like them can do to stop antibiotic resistance, when in fact, everyone can be part of the efforts to address this problem. 69% 51% 72% ESBL carriage rates in community according to geographical and temporal distribution. Each bubble area is proportional to size of corresponding study from 2002-2011. South East Asia CMR 2013;26:744 ESBL carriers in community in 2010 according to WHO region Stars represent countries with available data for modeling Each bubble area is proportional to the estimated number of ESBL carriers in that region CMR 2013;26:744  Action 5. Regulate antibiotic distribution in humans & food animals & agriculture & industry • Agriculture H • Industry
Ethanol production from sugarcane Antibiotic Injection Antibiotic Spray 14 April 2016 Action Framework for Implementing the Ministerial Communique Dr Vivian Lin Director Division of Health Systems WHO Regional Office for the Western Pacific Bi-regional Technical Consultation on Antimicrobial Resistance in Asia 14-15 April, Tokyo, Japan Ministerial Communique • Control of Antimicrobial Resistance requires coordinated strategies involving multiple sectors: – Human health – Animal health – Agriculture, food safety, food production – Environmental protection sectors • Call for collective action at the national, regional and global level Antimicrobial Resistance Antimicrobial Resistance Antimicrobial Resistance Antimicrobial Resistance 14 April 2016 Antimicrobial Resistance Awareness and Advocacy UHC Building resilient health system to contain AMR - UHC UHC ‘One Health’ ‘One Health’ – a multisectoral approach to AMR UHC ‘One Health’ SDGs Containment of AMR as a Development Agenda UHC ‘One Health’ SDGs GOVERNANCE OF AMR as a development agenda National, Regional and Global actions to contain AMR UHC ‘One Health’ SDGs GOVERNANCE OF AMR as a development agenda Enhance R&D (new antibiotics and diagnostics) National Regional Global Harmonization of surveillance and regulations National Action Plan on AMR National, Regional and Global actions to contain AMR 14 April 2016 Towards an Integrated Approach to Antimicrobial Resistance and Universal Health Coverage Dr Vivian Lin Director Division of Health Systems WHO Regional Office for the Western Pacific Bi-regional Technical Consultation on Antimicrobial Resistance in Asia 14-15 April, Tokyo, Japan What actions in the health sector? • Infection prevention and control • Antimicrobial stewardship programs • Regulating access to and quality of antibiotics What underlying challenges? • Infection burden (due to contaminated water and food, untreated infectious diseases, etc) • Community expectations of access to powerful medicines • Lack of or inappropriate treatment guidelines • Motivation for sales of antibiotics • Insufficient regulation or their enforcement 3 UHC actions for addressing AMR Health System Attributes Key issue to be addressed for AMR Actions to address AMR Equity Is there equitable access to measures to prevent and treat infections? Reduce burden of infection Ensure access to appropriate antibiotics Balance access and restrictions Quality Are antimicrobials of sufficient quality and used appropriately? Regulate and assure quality Train health workers continuously Efficiency Are there unnecessary expenses from overuse? Is there a need to improve prescribers behaviours? Alter financial incentives to correct overuse Monitor prescribers / hospital performance and antibiotic consumption. Accountability Are users and providers adequately informed about how to use antimicrobials and reduce the risk of resistance? Provide information on surveillance of AMR, health care associated infections and appropriate treatments compared to local or national antibiotic guidelines Sustainability and resilience How can long-term efficacy of antimicrobials be preserved? Strengthen public health services Build social coalitions with public and private sectors and the community Invest in R&D for new drugs and diagnostics 4 Conclusions • UHC is foundational for addressing the interdependent drivers for AMR in the health system • Tackling AMR requires actions on UHC • UHC strategies need to take account of AMR 5 14 April 2016 Session 4 - Panel discussion SLOWING DOWN ANTIMICROBIAL RESISTANCE THROUGH STRONGER HEALTH SYSTEMS THE ROLE OF UNIVERSAL HEALTH COVERAGE (UHC) National health systems and governance of AMR Professor Ramon Z. Shaban Temporary Advisor WHO WPRO 1 The Context • Prevention and containment of AMR requires systematic and coordinated efforts that transect and transcend sectors: – Human health – Animal health – Agriculture, food safety, food production – Environmental protection • Requires collective national, regional and global action • Whole-of-society, all citizens • Infection prevention and control • Antimicrobial stewardship programs • Regulating access to and quality of antibiotics • Infection and disease burden (via contaminated water/food, untreated ID and conditions, etc) • Community expectations of access to antibiotics • Lack of, or inappropriate adherence to, treatment guidelines and evidence • Drug discovery, R&D, and the motivation for sales of antibiotics • Insufficient regulation or their enforcement • Individuals, communities, whole-of-society • Fundamentality of UHC 2 Strategy-aligned Systemsa 3 Lin V. (2016). AMR and UHC. Bi-regional Technical Consultation on AMR in Asia. WHO WPRO. 14-15 April, Tokyo, Japan. Building robust systems for AMR with UHC 4 Lin V. (2016). AMR and UHC. Bi-regional Technical Consultation on AMR in Asia. WHO WPRO. 14-15 April, Tokyo, Japan. Building robust national systems • Goes beyond single disease or species approach • Centered in One Health • Coordinated national systems that are internationally-integrated Element 1 – Governance, Regulation and Standards for AMR Element 2 – Comprehensive, integrated national surveillance Element 3 – Antimicrobial stewardship and reduced antibiotic use Element 4 – Systematic Infection Prevention and Control Programs Element 5 – Research and Development Element 6 – Education, Communication and Stakeholder Engagement 5 The Elements and their scope 6 14 April 2016 System capability and response for addressing AMR through UHC Health System Attributes Key issue to be addressed for AMR Actions to address AMR Equity Is there equitable access to measures to prevent and treat infections? Reduce burden of infection Ensure access to appropriate antibiotics Balance access and restrictions Quality Are antimicrobials of sufficient quality and used appropriately? Regulate and assure quality Train health workers continuously Efficiency Are there unnecessary expenses from overuse? Is there a need to improve prescribers behaviours? Alter financial incentives to correct overuse Monitor prescribers / hospital performance and antibiotic consumption. Accountability Are users and providers adequately informed about how to use antimicrobials and reduce the risk of resistance? Provide information on surveillance of AMR, health care associated infections and appropriate treatments compared to local or national antibiotic guidelines Sustainability and resilience How can long-term efficacy of antimicrobials be preserved? Strengthen public health services Build social coalitions with public and private sectors and the community Invest in R&D for new drugs and diagnostics 7 Action outcomes for AMR and UHC • Population-level decrease the burden of infections • Ensure access by individuals to efective and appropriate treatment of infections • Ensure access to reliable information and advice • Reliable, effective and efficient drug systems • Effective and efficient EB treatment protocols • Sustainable finance and value for the health dollar • Promulgate partnerships • Contain and prevent AMR • Equity • Quality • Efficiency • Accountability • Sustainability and Resilience 8 14 April 2016 Antimicrobial Resistance A Threat to Sustainable Development Prof. Otto Cars, Uppsala University Sweden Bi-regional Technical Consultation on Antimicrobial Resistance Tokyo, April 14 , 2016 ‘We will equally accelerate the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis, hepatitis, Ebola and other communicable diseases and epidemics, including by addressing growing antimicrobial resistance and the problem of unattended diseases affecting developing countries’ Transforming our world: the 2030 Agenda for Sustainable Development Transforming our world: the 2030 Agenda for Sustainable Development Antimicrobials are fundamental components of all health systems Lack of access to effective antibiotics is causing millions of deaths About 70% of neonatal systemic infections can not be treated with the antibiotics recommended by WHO…. Lancet 2005; 365: 1175–88 “Across developing countries fewer than a third of children with suspected pneumonia receive antibiotics” United Nations Children’s Fund (UNICEF) June 2012 Antibiotics The cornerstones of basic and modern medicine Wound infections Urinary tract infections Pneumonia Blood infections Gonorrhoea Preterm babies Complicated deliveries Hip Replacemen t Organ Transplants Cancer Treatment Maternal and child health Modern medicine Basic health care 14 April 2016 By 2030: Reduce the global maternal mortality ratio to less than 70 per 100,000 live births End preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all Strengthen the capacity of all countries, in particular developing countries, for early warning risk reduction and management of national and global health risks AMR strikes hardest on the poor “...more than any other issue, poverty and inadequate access to drugs continue to be a major force in the development of resistance.”* Treatment of drug resistant infections: • Costlier • Takes longer • Has lower chances of success As a result , AMR negatively impacts national and individual economy. * World Health Organization. Overcoming antimicrobial resistance. World Health Organization’s report on infectious diseases. 2000. Loss of first line drugs increases drug costs Source: WHO Policy Perspective 2005, adapted from WHO Model Formulary, WHO Clinical Guidelines and Management Sciences for Health’s 2004 International Drug Price Indicator Guide (slide courtesy: David Heymann) Non-human use of antibiotics 2010-2030*
Increasing demand for animal protein
Projected increase of the consumption of antimicrobials in the food animal sector by 2/3 But, there are examples where productivity is reached without use of antibiotics for growth promotion and routine medication Need for regional and context specific transformation strategies towards sustainable practices Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, et al. Global trends in antimicrobial use in food animals. Proc Natl Acad Sci U S A. 2015 Mar 19;112(18):5649–54. Clean water and sanitation • Antibiotic residues from hospitals, antibiotic manufacturing plants and agriculture can be carried by water. • Even very low antibiotic concentrations may be enough to select for highly resistant bacteria. • Lack of access to clean water and sanitation facilitates the spread of bacterial diseases leading to increased morbidity and mortality, especially in children. US$100 trillion by 2050* The costs for antibiotic resistance reach far beyond the health sector *R.D. Smith et al. / Journal of Health Economics 24 (2005) 1055–1075 * Review on Antimicrobial Resistance. Review on Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations. (2014). 14 April 2016 Balancing access, innovation ,conservation “The infrastructure of antibiotic discovery both in academia and in industry is at a dangerously low level and needs to be rebuilt” The Global Costs of Irrational Antibiotic Use The suboptimal use of antibiotic costs $55 BN/year ≈ 0.9% of global total health expenditure IMS Report Ministerial meeting Amsterdam, 2012 New antibiotics Fixing the leaking system Marketing Volume sales Misaligned financial incentives Irrational use of antibiotics Lack of access to affordable health care Backbone of an intersectorial action • Multi-stakeholder partnerships • Means of Implementation for technology and capacity building • Data, monitoring and accountability 15 April 2016 AMR as regional health security challenge requiring urgent national activity Haruo Watanabe As a national actin plan, each country is requested to address to the five objectives; ① improving awareness and understanding to AMR ② surveillance and research ③ reducing infection rates ④ optimizing use of antibiotics ⑤ sustainable investments for new medicine, diagnostics tools, vaccines and others, In the yesterday’s discussion, we recognized the importance of these five objectives in order to combat with the AMR. Today, I want to show the necessity of One Health approach from the emergence of novel resistant strains Recent problems: Emerging Carbapenem-resistant enterobacteriaceae (CRE) Lancet Infect Dis Aug. 11, 2010 Emergence of NDM-1 resistant strains in India Superbug; 10-fold increase of “Nightmare Bacteria; CRE” of E.coli (NDM-1) and K.pneumoniae (KPC) during these 10 years in USA Superbug CRE a growing threat among young childrenReuters/CDC Superbug CRE a growing threat among young children、CBS News Nature 2013. 499:394 Limited choice of antibiotics for treatment: Last-resort antibiotics for treating infections due to CRE: Colistin and Tigecycline （CIA:Critically Important Agents designated by AGISAR, WHO) Colistin was found in 1950 by Japanese researcher. It fell out of favor due to its nephrotoxicity to human of CRE Emergence and dissemination of plasmid-mediated colistin resistant(mcr-1) Enrerobacteriaceae bacteria High frequent isolation of mcr-1 positive E.coli in China (mcr-1 gene: phosphoethanolamine transferase enzyme family, which modifies LPS, a target by colistin ) Data: 21% of E.coli isolates of food animal feces (pig) 15% of E.coli of retail meats (pork and chicken) 1% of E.coli of inpatient Subsequently, isolation of mcr-1 carrying strains in E.coli, K. pneumonia, Salmonella and etc. has been reported from various countries including Asia, EU and others. (Yi-Yun Liu et al; published on line; Lancet Infectious Dis、November 18, 2015) Presence of mcr-1 and colistin resistance in Escherichia coli of chicken origin during 1970–2014 in China (Shen Zhanggi et al. Lancet. Infect. Dis. 16:293. 2016) Mcr-1 strains were isolated in 1980s. The proportion of mcr-1 positive E.coli increased from 2009, which may be due to the increased use of colistin during the past 5 years (annual use of colistin; ranging 2470 to 2875 metric tons by the Lancet Inf. Dis. paper). 15 April 2016 Figure Lancethe Lancet Infectious Diseases 2016 16, 146-147DOI: (10.1016/S1473-3099(15)00533-2) Detection of mcr-1 gene from human commensal gut flora of healthy persons (Yongfei Hu et al. Lancet Infect Disease 16:146, 2016) mcr-1 gene existed in the human commensal gut flora of healthy persons. The gene was flanked by insertion sequences, indicating mcr-1 gene can be transposed as mobile elements. The gene may have been introduced into the human flora (mirobiome) through the food chain dissemination pathway. The mcr-1 gene in the human flora has a potential to be disseminated among human when colistin is used as a selective pressure. Commensal bacteria of healthy human mcr insertion sequence mcr accumulation Genetic background: dissemination of mcr-1 gene dissemination by a potential food chain pathway mcr Plasmid Flora bacteria of animals (chicken etc.). Selective pressure by the use of colistin Gut flora of human 1) emergence of mcr-1 gene in somewhere (probably originated from some bacteria) 2) accumulation of mcr-1 gene on the plasmid with other resistance genes in animal gut flora bacteria through mobile elements under the natural conditions 3) use of colistin to the food animals and selective growth of mcr-1 positive strains 4) transfer of mcr-1 positive plasmid into human gut flora bacteria by a potential food chain dissemination pathway blatet 1)Emergence of ndm-1 and mcr-1 positive bacteria, which was first reported in Asian region, is now becoming a big human health security problem in the world. We have little choice for the treatment of patients infected by such resistant bacteria. 2) This is a typical example: naturally emerged-drug resistance gene or its stain is selected and grown in food animals by the use of critically important drugs(CIA) for human, and disseminated from food animals to human through the potential food chain pathway. 3) If we do not properly respond to stop its further dissemination with the cooperation of human and veterinary health sectors, we shall have difficulties for the treatment of patients. Now it is indeed a time to implement urgent action by “One Health” approach. 4) From now, we will listen to the presentation of national action plans from each country. We expect each country is addressing itself to the recognition of importance of AMR problem , and the development and implementation of national action plan according to the global action plan by WHO. Conclusion 15 April 2016 Reflections on governance of AMR National mechanisms, challenges and next steps for development and implementation of national action plans Mr Graeme Barden Assistant Secretary Health Protection Policy Branch Office of Health Protection Australian Government Department of Health www.health.gov.au/amr 0 • Responding to AMR is a high priority of the Australian Government • Australia’s One Health National AMR Strategy was released in June 2015 o Collective, expert views of stakeholders o Supported by an implementation plan o Aligned with the WHO Global Action Plan • Builds on past and current efforts in Australia to respond to AMR Australia’s First National Antimicrobial Resistance Strategy 2015-2019 www.health.gov.au/amr 1 Developing a national action plan on AMR with a One Health approach – Key challenges • Identifying key government partners and obtaining agreement to proceed • Fully understanding the current situation and key initiatives already in place on which to build • Making the case – why a national AMR plan is critical • Establishing clear governance arrangements and promoting a collaborative approach • Effectively engaging key stakeholders early on, inviting submissions and facilitating multi-sectoral discussion www.health.gov.au/amr 2 AMR Prevention and Containment Steering Group Head of Department of Health Head of Department of Agriculture and Water Resources Chief Medical Officer Chief Veterinary Officer Provides leadership on AMR, oversee development & implementation of the National AMR Strategy Australian Strategic and Technical Advisory Group on AMR Expert stakeholder representatives from across human health, animal health, agriculture & food, as well as state government. Expert advice to the Steering Group on implementation of the National AMR Strategy Who are the key stakeholders? Australian Government Minister for Health Minister for Agriculture and Water Resources National AMR Forum 170+ stakeholder representatives from across all sectors coming together AMR affects the whole community www.health.gov.au/amr 3 Main achievements of Australia’s approach • Recognises past and current efforts to respond to AMR • Identifies clear priority areas for action to focus future efforts • Capitalises on success and seeks to better integrate efforts to address gaps and ensure a more comprehensive response to AMR in Australia • Stakeholders are engaged and working collaboratively - activities not just led by government - all stakeholders are leading and contributing • Established enhanced surveillance in human health to better inform actions and measure success www.health.gov.au/amr 4 www.health.gov.au/amr Accountability and transparency – mechanisms for monitoring and evaluation • Responsibility for the implementation of Australia’s National AMR Strategy sits with the high-level AMR Steering Group • Enhanced surveillance is a key objective of Australia’s National AMR Strategy - data will be used to monitor and evaluate success • Targets and indicators will be developed to focus efforts and measure progress • Annual reports will outline the progress in achieving the objectives of the National AMR Strategy. These will be publicly released. 5 15 April 2016 www.health.gov.au/amr Key success factors and next steps • Providing opportunities for stakeholders to express views and opinions is critical • Promote the message that AMR is everyone’s responsibility – steer away from assigning blame and focus on action • Invest in surveillance – this informs action and measures progress • Strong leadership Australia’s next steps: o Finalising the Implementation Plan - progress will be made over five years of the Strategy, starting with highest priorities first o Using our enhanced surveillance data to future inform actions o Measuring success and releasing public progress reports o Continuing to support global efforts to combat AMR 6 15 April 2016 ARC on a move: Bangladesh Directorate of Disease Control Ministry of Health and Family Welfare To look for • March, 2016 data • General consideration • Strategic progress • Activities undertaken • Way forward Science transformed to Rhyme • AB saved lives for many years effectively • Including human, domestic birds and animal equally • Became essential for the world • Blamed with bad effects afterward • AB is not causing injury to host’s health • Germs are obtaining power to cause death • Excessive use, overuse, unnecessary use, irrational use whatever the act • Microbes struggled to make their existence, as a matter of fact • High cost have to pay to cure infection • Morbid days of course hamper daily production • Challenge for the rich and poor not the easy issue • Meeting, sitting, eating business started giving what so? Basic Data • Total area: 147,570 km² • Population: 160,195,860 • Health Administration: Ministry of Health and Family Welfare has: – Directorate General of Health Services – Directorate General of Family Planning – Directorate General of Drug Administration – Nursing Council • Development Partners: UN agencies, JICA, US-CDC, NGOs • Pharmaceutical Industries: 199 (all have AM products) 15 April 2016 Basic data • Public Health Care Delivery tires: – Primary: Community Clinics, Union Sub-center, FWC, Upazila (sub-district) Health Complex – Secondary: District hospitals – Tertiary: Medical College Hospitals – Specialized: NICVD, NIKDU, NITOR, NINS, NIDCH, ENTI, NICRH….. • Health care providers: Specialist and Graduate doctors, Nurses, Paramedics, Field staff, CHCPs • Private sectors: Multi-national entrepreneur, Local investors, Joint venture • Drug (medicine) selling policy: Prescription only drugs (POD), Over the Counter (OTC) drugs through licensed medicine shops **** Antimicrobials are OTC drugs, so any body can buy it from any medicine shops (human and animal regime). ARC on a move • Level of Political commitment: High, ARC been declared as a “Medical Revolution” • National strategy approved (18/05/2015) addressing following aspects: – Establishing a multi-sectoral approach for planning and coordination of activities related to AMR; – Promoting and ensuring rational use of antimicrobials; – Promoting and strengthening infection prevention and control measures; – Promoting and strengthening biosafety and biosecurity principles and practices and containment measures National strategy approved (18/05/2015) addressing following aspects: – To review, update and strengthening of regulatory provisions – Institutionalizing a surveillance system for AMR containment; – Promoting operational and basic research – Continuing education in the area of AMR; – Establishing advocacy, communication and social mobilization (ACSM); – Developing new AMs and vaccines Planning and Coordination • Prevention and containment of AMR requires integrated and well- coordinated efforts among stakeholders at different levels of health, veterinary and fishery of both public and private sectors. • For planning and coordination of activities, following committees are being developed with their respective terms of reference (TOR): • A. National Steering Committee (NSC) • B. National Technical Committee (NTC) • C. Core Working Group at DGHS • D. Committee for Tertiary Level Hospital • E. District Multisectoral Committee • F. Upazilla Multisectoral Committee • G. Committees in Clinical Services Delivery setup **D-G are yet to be made functional Development of National Action Plan: • December 2015: Development of draft National Action Plan for Antimicrobial Resistance Containment in Bangladesh” by CWG • January- February 2016: Two consultative workshops on draft National Action Plan for Antimicrobial Resistance Containment in Bangladesh” Development of Institutional Antimicrobial Guideline: • January 2012: Meeting on “Development of Institutional Guideline for Antimicrobial use and Infection Prevention & Control (IPC) measures” for ARC organized by Disease Control Unit, CDC, DGHS • July 2012: Consultative workshop on “Introducing Antibiotic Policy and Guideline at Dhaka Medical College Hospital” organized by Disease Control Unit, CDC, DGHS • July 2012: Formation of core committee for development of draft “Institutional Antibiotic Policy and Guideline at Dhaka Medical College Hospital” organized by Disease Control Unit, CDC, DGHS 15 April 2016 ARC activities • April 2013: Development of draft “Institutional Antimicrobial Guideline for DMCH” organized by Disease Control Unit, CDC, DGHS • June 2013: 1st consultative workshop on draft “Institutional Antimicrobial Guideline for DMCH” organized by Disease Control Unit, CDC, DGHS ARC activities • October 2013: 2nd consultative workshop on draft “Institutional Antimicrobial Guideline for DMCH” organized by Disease Control Unit, CDC, DGHS • May 2014: Consultative workshop for finalization of draft on “Institutional Antimicrobial Guideline for DMCH” organized by Disease Control Unit, CDC, DGHS • June 2014: One day orientation of specialist doctors from fifteen Medical College & Hospitals on “development of “Institutional Antimicrobial Guideline” organized by Disease Control Unit, CDC, DGHS Strategic actions • Laboratory strengthening & Capacity building: • November 2015-February 2016: Conducting four days hands-on training to microbiologist and laboratory technicians from 15 medical colleges on “Antibiotic susceptibility test” and reporting • November 2015-February 2016: Distribution of kits and necessary reagents to microbiology laboratory of 10 medical colleges for conducting “Antibiotic susceptibility test” for uniform reporting Strategic actions • Advocacy, communication and social mobilization: • April 2015: 1st National Symposium on “Antimicrobial Resistance Containment” for Upazilla Health & Family Planning officers organized by Disease Control Unit, CDC, DGHS • 2015-2016: Conduction of ten advocacy meetings in different medical college hospitals/district hospital for awareness rising about AMR • November: Observed Antibiotic week declared by WHO ARC on a move • Five years National Action Plan drafted – To cope up ARC with upcoming HPNSDP-II (2016- 2021) • Awareness and BCC activities running with the involvement of media • Orientation and advocacy on ARC have been undertaken including academia, policy makers, Health managers, Nurses and Field staff

,          
!"  #$%  15 April 2016 Bangladesh Needs to Implement regulations •Animal Disease Act, 2005; Animal disease rule, 2010; •Fish feed and animal feed Act, 2010; •Fish feed rule, 2010; •Animal feed rule, 2013; •National livestock Policy, 2007; •National Poultry Development Policy, 2008, •International regulations in use of AMs in animal and fisheries; •National Food Safety Commission Ordinance 2013 •Safe Food Laws 2013 International Collaboration and Partnership • ACSM (JOCV, UNICEF, WHO) • Capacity building of HR by training and education (Academy, Development partners, Industry sectors) • Establishing world class drug testing Laboratories • Technical assistance for comprehensive surveillance, monitoring and evaluation • Advanced research and data sharing mechanisms • Logistics support • Any strategic point???????????? IEDCR New Building Foundation Works, but research is the foundation for planning any public health program Research on: AMR acquisition, molecular Epidemiology, Rapid detection of Resistant Bugs, Alternatives to AMR, Prediction tools…… Expectations from drug and vaccine Industries • Accept the invitation to be the stakeholder for ARC program • Quality low cost AM for country use in accord with GMP • Quality products for export and contribution to GDP • Manufacturing effective vaccines to use against vaccine preventable diseases • Saturation of the market • Research conduction and support to develop new AM molecules • Advocacy and communication with policy and decision makers as well as common people • Market promotion principle should be “right product to right persons, right sectors and right tires at right times 15 April 2016
National Health and Family Planning Commission of the People’s Republic of China has always attached great importance to clinical application of antibiotic management Policy 2 Achievements
Established national Surveillance systems and mechanisms Center for Antimicrobial System (CAS, 2005) China Antimicrobial Resistance Surveillance System (CARSS, 2005)
Improved the system of management and technical specifications The Administrative measures of clinical application of ABX The Guiding Principles of the Clinical Application of Antibiotic The National Guideline of Antimicrobial
Three Year Special Activities on Clinical Administration of Antibiotic Antibiotic varieties gauge number  Prescription frequency Intensity of antibiotic use in hospitals
Established internal-administerial cooperation mechanism Joint Prevention and Control work mechanism of bacteria resistance Containing AMR action plan of China (2016-2020) 3 Key Challenges
The ability of physician on diagnosis and treatment of infectious diseases
Misuse or overuse of antibiotic in individual
Lack of microbiological testing and clinical pharmacy technical support system
Low level of medical knowledge among grassroots HCWs
Pressure of getting ABX from patients, esp. from pediatric patients’ family 4 Key Challenges Cont.
New type of antibiotic development power shortage and excess production capacity
Over-the-counter sales of antibiotic without prescription in some pharmacy
Antibiotic breeding over dose, beyond scope and poor withdrawal time appliance
Antibiotic production enterprises waste emissions are not standard
The public consciousness of rational drug use is still low 5 Action Plan
Strengthen the multi-sectoral and interdisciplinary cooperation
Improve and promote the Containing Antimicrobial Resistance Action Plan (2016-2020)
Implement the comprehensive governance policies and measures to push the antibiotic research
Push development and production as well as other related areas
Strengthen managements in health, agriculture, medicine circulation sales
Increase the propaganda intensity of antibiotic pollution prevention and control as well as the public education 6 15 April 2016 Containing AMR Action Plan in China 2016-2020
Improve the ability of prevention and control of bacteria resistance among medical staff, animal husbandry and veterinary practitioners
Establish and improve the surveillance and monitoring system of bacteria resistance and antibiotic application
Strengthen the rational use of antibiotic and drug resistance control system in health care and breeding
Strengthen the building of capacity of antimicrobial pharmaceutical enterprise environmental regulation and antimicrobial pollutants environmental monitoring
Vigorously develop new antibacterial drugs, vaccines, equipment, new technology and new projects
Increase public awareness of rational use of antibiotic
Carry out extensive international exchanges and cooperation in the field of bacteria resistance 7 8 15 April 2016 Governance mechanism to implement National Action Plan (NAP) on AMR INDIA INDIA • India has one doctor per 1700 patients • 70% of health care is dispensed through private sector, alternate system practitioners • Prescribing practices: evidenced based treatment guidelines • Consumer practices: self prescription, noncompliance • Regulations around antibiotics sale • Infectious disease specialists/guidelines missing link • Diagnostics under recognized underexploited tool for resistance containment Goals of National Action plan (under development) • Slow the Emergence and Spread of Resistant Infections. • Strengthen National One-Health Surveillance Efforts • Encourage and Accelerate Research and Development for New Antibiotics and Therapeutics • Advance Development of Rapid Diagnostic Tests for Identification and Characterization of Resistant Bacteria. • Improve Capacities for Prevention, Surveillance, Control of drug resistant infections and Antibiotic Research and Development through international collaborations Current stake holders • Ministry of Health and Family Welfare – Drugs Controller General of India – National Center for Disease Control – Indian Council of Medical Research – Department of Biotechnology • Ministry of Agriculture and Livestock • Private Sector • Professional bodies, NGOs Current status • National Antibiotic policy(2011) • Established surveillance network: harmonisation of lab practices by creating SOPs to be followed across the laborataries • Schedule H1 introduced to monitor sale of antibiotics third generation antibiotics and all newer molecules like Carbapenems • Move to ban fixed dose antibiotic combinations • Infection control guidelines released by MOHFW • Regulations for use of antibiotics in animals: – Drug and Cosmetics Rules, 1945 – Food Safety and Standards Regulations 2011: guidelines for aquaculture • http://www.drugscontrol.org/amendments.asp?act=Drugs%20and%20Cosmetics%20Rules,%201945 Drug and Cosmetics Rules, 1945 Rule 97 • Agriculture ministry’s notification asked enforcement agencies in all states to discourage the overuse of antibiotics by the industry and veterinary surgeons along with strict instructions to the drug industry to label antibiotics intended to be used in animals with a specific withdrawal period. 15 April 2016 Strengthening Surveillance • Two surveillance networks: – National Center for Disease Control: nation wide estimates (10 hospitals) – Indian Council of Medical Research: 4 hospitals • Strengthen research around surveillance, understanding at molecular to understand trends, patterns, clonality, transmission dynamics • Use data to devise evidence based treatment guidelines • Nodal centres are focal points for six pathogenic groups: – Enterobacteriaceae / sepsis (PGIMER) – Gram negative non-fermenters (CMC) – Enteric fever organisms (AIIMS) – Diarrhoeagenic organisms (CMC) – MRSA, Enterococcus (JIPMER) – Fungal pathogens (PGIMER) – Data management unit in Bioinformatics Center, ICMR Hqs • 15 Regional Centres (RC) proposed Nodal Centres PGIMER Chandigarh AIIMS New Delhi CMC Vellore JIPMER Puducherry Antimicrobial Research and Surveillance Network at ICMR ICMR, New Delhi Key findings from Surveillance Network • Salmonella typhi – 100% sensitive to ampicillin, chloramphenicol and cotrimoxazole, cefixime – High resistance to FQ, Ciprofloxacn in S. typhi is increasingly reported • Enterobacteriaceae – Klebsiella spp. and E. coli cause most of infections – 100% sensitive to colistin followed by imipenem and meropenem(60%) – E. coli NDM at 58%, Oxa-48 at 18%, NDM+Oxa-48 at 14% respectively – Klebsiella Pneumoniae, Oxa-48 (55 %), NDM producers (24%); co- producers of NDM+Oxa-48(16%) Key findings from Surveillance Network •Acinetobacter species 60% isolates, Pseudomonas species 24%, Strophomonas species 4% , Burkholderia species 4%. •A baumanii isolates showed maximum susceptibility was to colistin (99%) followed by imipenem (53%) and meropenem (53%). •Susceptibility for amikacin has increased by 23% from 2014-2015 •All isolates of P aeruginosa were susceptible to colistin, followed by imipenem (85%), amikacin (80%), ciprofloxacin (80%), piperacillin-tazobactam (58%) and meropenem (50%) •Almost all antibiotics seems to have >70% susceptibility Multiple resistance coding gene presence Pseudomonas aeruginosa and Acinetobacter baumannii
the reason for increased MIC
resulting in requirement of combination therapy with high dose and extended duration. Key findings from Surveillance Network • Gram positive infections – MRSA 60% – CoNS: Methicillin resistance 60%, Vancomycin resistance 4%, Mupirocin 25% – Enterococcus faecium: Vancomycin resistance 14% • Fungal infections – Fluconazole resistance C. albicans (18.9%) C.parapsilosis (10 %) and C. tropicalis (5.6 %). – Voriconazole resistance 13.2% of C. albicans. – C. glabrata exhibited 11.8 % resistance to Micafungin, (8.8%) to caspofungin followed by (6.1%) to posaconazole – C. krusei had 5.6% resistance to anidulafungin PGIMER CMC Vellore JIPMER % sensitivity Cefotaxime <10 30 19 Cef-sulbatam 50 80 80 Amikacin 78 >90 83 Ceftazidime 8 25 30 E. coli from blood Klebsiella spp from blood PGIMER CMC Vellore JIPMER % sensitivity Cefotaxime <10 40 6 Cef- sulbatam 20 60 32 Amikacin <40 60 42 Ceftazidime 8 40 8 Pip-Tazo 30 45 **** Antimicrobial Surveillance and Research network Hospitals with better antibiotic stewardship practices have high susceptibility patterns 15 April 2016 • 20 Hospitals: 13 public and 7 private • Accreditations better in private hospitals • AMSP documents in 4/20 hospitals • Infection control document in 20/20 • Most hospitals did not have infectious disease physicians and clinical pharmacists Survey of AMSP Practices 2013 • Anti Microbial Resistance Data Analysis 20/20 • Anti Microbial Agents Usage Data Analysis 5/20 • AMA Prescription Audit & Feedback practised by 2/20 • Comprehensive treatment guidelines missing in most hospitals • Syndrome specific guidelines frequently available • AMSP not linked with IT system in most hospitals Building collaborations
Center for Disease Control, USA
Strengthening infection control
National Institute of Allergy and Infectious Diseases, NIH, USA
Systems biology of AMR
Epidemiology of neonatal sepsis
Clinical trials for new entities
Research Council Norway, Norway
Methods for assessment of the burden of resistance
Integrated project surveillance systems for AMR and antibiotic use in humans and/or animals.
Ecological, evolutionary and molecular studies of AMR in clinical and non-clinical environments.
National Institute of Infectious Diseases, Japan: LoI under process Key challenges • Inter-sectoral linkages • Getting all the stakeholders on board • Implementation of policies laid out so far • Reaching out to the large and diverse private sector health care institutions • Surveillance data on drug resistance in animals and animal products • Academia-Government-Industry partnerships Next steps • Create a mechanism for inter-sectoral coordination • Sustain and strengthen quality data collection, its dissemination and utilisation • Use the data being generated to guide policies • Engagement with animal husbandry: surveillance mechanisms and policy implementation • Engagement with professional bodies on adoption of guidelines • Create mechanisms to strengthen Academia-Industry partnerships 15 April 2016 Governance Mechanism to Implement National Action Plan (NAP) on AMR Indonesia Introduction, background; current status of NAP • Current status NAP : Under development launched – will be reviewed by SEARO WHO consultant. • Strategic plan of AMR Controlling Program in Human Sector has been established since 2005 and launched by ARCC Ministry of Health – AMR Controlling Programs in hospitals, primary health care and community is being implemented • Collaboration between MoH and MoA has been initiated Im plem entatio n of A M R surveilla nce A vaibility of A M R control P rogram funds OUTCOME OUT PUT STR ATE GIC IMPL EME NTA TION PRO CES HEAL TH PRO VIDE R Update of AMR teaching material in Health education (Medical Doctor, Pharmacetical, Nurse, Midwife) Collaboration between Ministry of health, ministry of Agriculture and veterinary, ministry of education Collaborati on among health faculty / university Collaborati on of medical profession collegium Collaborat ion of ministry of agriculture and veterinary Collaboratio n between institution that concern in antibiotic use ( Increasing Public Health quality through AMR Control Program (Diagnostic, Antibiotik usage, Infection management, AMR Spreading, Decreasing AMR Incidence ) To Develop AMR Control Implementation in Health Facilities ( % number of Health Facility included) Realization of Community Care toward AMR Global Problem and control (% understanding of AMR, % antibiotic consumption,% decreasing antibiotic OTC)) Realization of AMR Control collaboration within profesional organization Realization of AMR Control in Primary Health Facilities Realization of AMR Control in Private Practice setting Realization of AMR Control in Hospital Realization of education system of AMR Problem and control in community Realization of antibiotic selling control and monitoring Realization of collaboration between gov. and NGO Avalaible competent health provider in for AMR conrtol program: (Phycisian, Clinical Microbiologist, Clinical pharmacist, Clinical Pharmacologist, ICN) Facilities support for AMR Control program : (Diagnostic, IC, Pharmaceutical fascilities) Gov. Regulation support (National Policy, National guideline, Clinical guideline) Existing system of AMR control in Health facilities and community Realization of AMR Information system base on health facilities Realization of AMR Information system base on community setting Strategic Map of AMR Control in Indonesia 2015-2019 3 Key challenges to start development of NAP on AMR with One Health approach 1. National focal point should be established 2. Understanding about the national and global AMR problems 3. Regulation and guideline implementation 4. Enhance law enforcement 5. Multisectoral collaboration: government institutions, academics, and health professional organizations Key stakeholders Current governance and oversight stuctures/processes to bring together various sector Actors in NAP Ministry of Health Ministry of Research and Higher Education National Agency of Drug and Food Control Ministry of Agriculture Ministry of Defense Ministry of Trade Professional and associations Academic Institutions Main milestone or plan for strategic planning; operational planning: budgeting and financing implementation of NAP 1. Development of national strategic plan and roadmap 2. Coordination among Ministries (Ministry of Agriculture, Ministry of Research, Technology, and Higher Education), professional organization 3. Development of national guidelines : a. AMU and AMR control in primary health care and hospitals b. Monitoring and surveillance of AMU and AMR in veterinary sector 4. Research related to AMR in community, primary health care and hospitals, animal products (poultry meat), and animal feed 5. Ministry of Health Decree regarding Antimicrobial Resistance Control Committee (ARCC) 6. Directorate General of Livestock and Animal Health Services Decree regarding AMR Control Team 7. Budgeting allocated by Ministry of Health and Ministry of Agriculture 15 April 2016 Accountability and transparency: mechanism for monitoring and evaluation of progress 1.Monitoring and evaluation attach in each activities by stakeholders 2.Data exchanges and share experiences among stakeholders Lessons learnt: key success factor for effective communication, collaboration and actions across sectors; Next steps Lesson learnt : 1. Pilot project ARCP in hospitals, including AMU and AMR 2. Monitoring on antibiotics use at primary health care 3. Community empowerment to improve awareness of AMU and AMR 4. Data availability to convince other stake holders Next steps : 1. To develop NAP supported by WHO SEARO 2. To ensure the establishment of National focal point 3. To promote rational use of antimicrobials 4. To promote national surveillance on AMU and AMR 15 April 2016 Governance mechanism to implement National Action Plan (NAP) on AMR Yukiko NAKATANI National Focal Point on AMR, Japan April 15, 2016 Ministry of Health, Labour and Welfare Government of Japan 1 Background • Japan has been tackling AMR issues since mid-1990s, including following activities; – 1996: Installed economic incentives to promote infection, prevention and control (IPC) in medical institutions (revised several times) – 1999: Initiated the Japanese Veterinary AMR Monitoring (JVARM) System – 2000: Initiated the Japan Nosocomial Infection Surveillance System (JANIS) – 2004: Initiated risk analyses of effect of antibiotic-resistant bacteria in foods selected by livestock antibiotic use on human health – 2006: Revised a law to mandate all medical institutions to install guidelines and governance committees on IPC – 2013: Installed economic incentives to promote antimicrobial stewardship and local peer-review on IPC in medical institutions – 2013: Started data linkage between JVARM, JANIS and AMR surveillance in food products – 2013: Published a guidelines on prudent use of animal antibiotics 2016: Launch a comprehensive, multi-sectoral National Action Plan on AMR Surveillance system Economic incentives Revision of Law Risk analyses 2 Challenges on NAP Development Brainstorming Stage Lack of coordination in AMR measures • We have been working on AMR separately without coordination. • Many stakeholders involved in AMR independently, Including human healthcare, animal health, food safety, research & development, international cooperation･･･ → Began with mapping overall picture of current AMR policies in Japan Development Stage Lack of data regarding health & economic burden of AMR in Japan • Difficulty in discussing importance of AMR issues with stakeholders without experience in AMR, in absence of health & economic burden data → Set up a national research team on measuring burden Strong political will helped multi-sectoral commitment • Strong leadership from the Health Minister Shiozaki contributed to the development of multi-sectoral NAP 3 Stakeholders and Governance MHLW Ministry of Health, Labour and Welfare MAFF Ministry of Agriculture, Forestry and Fisheries FSC/CAO Food Safety Commission, Cabinet Office Cabinet Secretariat (CAS) - Coordination Office of Measures on Emerging Infectious Diseases - Office of Healthcare Policy MEXT Ministry of Education, Culture, Sports, Science and Technology MOFA Ministry of Foreign Affairs MOE Ministry of the Environment NIID National Institute of Infectious Diseases NCGM National Center for Global Health and Medicine NVAL National Veterinary Assay Laboratory PMDA Pharmaceutical and Medical Devices Agency AMED Japan Agency for Medical Research and Development NARO National Agriculture and Food Research Organization FAMIC Food and Agricultural Materials Inspection Center JICA Japan International Cooperation Agency FRA Fisheries Research Agency Prime Minister’s Office - Ministerial Meeting on Measures on Emerging Infectious Diseases 4 Achievements • Operational Planning – Developed an internal operational worksheet which defines responsible division/office and working schedule for each actions • Strategic Planning – Used multi-sectoral One Health approach to integrate and enhance current national efforts against AMR – Compared NAPs of other countries (mainly G7) and best practices – Set numerical target based on the trends of AMR, antimicrobial uses and experiences from other countries • Budgeting/Financing – Prioritized budgeting for operational research for evidence-informed policy making (we can get budget or install policies in case we prove presence of scientific evidence generated within Japan’s context) 5 Monitoring and Evaluation Goal Strategy Action Responsible actors Cooperative actors Implementation Plan FY16 FY17 FY18 FY19 FY20 1 1.1 1.1.1 … IDC/HS/MHLW APSD/FSCA/MAFF NIID, NCGM … … … … … Working Framework Steering Committee on AMR National Action Plan / CAO Coordination Office of Measures on Emerging Infectious Diseases National coordinating mechanisms for specific issues - National Council on AMR / CAO Mainly focus on raising public awareness - Technical Advisory Board on AMR / MHLW & MAFF Discuss technical issues in AMR national action plan - One Health Surveillance Council on AMR / MHLW, MAFF, FSC & NOE Risk assessment and management based on One Health surveillance - Public-Private Partnership Platform for Global Infectious Diseases / CAO 6 15 April 2016 Lessons-learned and Next Step • Strong political commitments and leadership are crucial to formulate the multi-sectoral AMR national action plan. • Clarify responsibility and accountability for each action are important to move from “planning” phase to “implementation” phase. • Generating scientific evidence to guide AMR policies is important. Strong leadership Clarify responsibility and accountability Scientific evidence 7 15 April 2016 Governance mechanism to implement National Action Plan (NAP) on AMR MALAYSIA Introduction O Background O Activities by MOH on AMR has been ongoing for the past 13 years O MOH has expanded own activities year by year O Need of common platform with MOA MOE and Professional Societies to contain AMR O Current status of National Action Plan O AMR National Action Plan Workshop was held 21-23rd March 2016 O Multi-sectoral involvement -25 sectors involved including Professional societies O Participants : Medical Microbiologists, Infectious Disease Physicians, Veterinarians, Pharmacists, Scientists, Academicians, Food technologists, administrators Key challenges to start development of national action plan (NAP) on AMR with One Health approach O Conflicting perspective – human health only and animal health only O How to preserve human health without compromising on animal/ agricultural industry O Look for opportunities to have discourse and shared decision making between agencies O Form common platform for discussion O Lack of full time secretariat to coordinate and implement the NAP on AMR O Need to establish a Malaysia Antimicrobial Resistance Committee (MAREC) O Budgeting and financing to implement AMR containment activities across sectors O Key stakeholders O Ministry of Health Malaysia O Ministry of Agriculture, O Ministry of Education O Ministry of Science, Technology & innovation O Current governance and oversight structures / processes to bring together various sectors O Patient safety agenda under MOH – to influence activities in private hospitals O Antimicrobial Stewardship Program as a requirement for hospital accreditation including private hospitals O MOA –Feed Act 2009, MyGAP (Malaysia Good Agriculture Practice) Key stakeholders & Current governance Main achievements or Plans O a) Strategic planning O Establish a national committee (Malaysia Antimicrobial Resistance Committee (MARC) O co-chaired by DG of Health and DG of Department of Veterinary Services O Strengthen surveillance of antibiotic resistance among human, animal and agricultural sectors O b) operational planning; budgeting and financing implementation of NAP O plans for joint secretariat which should have its own budget to run its activities. O AMR containment activities O Awareness program O Training program to strengthen laboratory capacity, human resources O Monitoring and evaluation of all AMS programs Accountability and transparency: mechanism for monitoring and evaluation of progress of implementation O We hope that the joint committee will be the common platform where all data will be reviewed, discussed and common decisions will be made. 15 April 2016 Lessons learnt: Key success factor for effective communication, collaboration and actions across sectors & next steps O Control and monitor the use of antibiotics in farming. O Need to implement Antimicrobial stewardship program in animal health services O Inter-ministerial meeting/briefing on AMR 15 April 2016 Country Report on Antimicrobial Resistance The Republic of the Union of Myanmar Prof: Myint Han – DG, DOMS Dr Win Thein – Dir, NHL Located
South East Asia Area
676,600 sq km Neighboring Countries
India, Bangladesh, China, Thailand, and Laos PDR Human population
51millions (2014) The Republic Of Union of Myanmar Overview of problem of AMR in Myanmar • The emergence of resistance to antimicrobial agents is becoming a major public health problem all over the world including Myanmar • Culture and sensitivity of bacterial isolates done by National Health laboratory, Public Health Laboratory and State and Regional hospitals ₋ Automated culture & identification methods in NHL, YGH, MGH and some private hospitals ₋ Conventional methods in other hospitals • Supply of facilities for C & S in district hospitals was started only in 2015 Antibiotic Resistance pattern of Escherichia coli (2013) Antibiotics Resistance rate (%) Number of tested isolates Surveillance site Cefotaxime 57 171 NHL+PHL+MGH +NOGH Ceftriaxone 67 574 NHL+PHL+MGH +NOGH Ceftazidime 47 451 NHL+PHL+MGH +NOGH CTX, CAZ, CRO 40 42 NHL+NOGH Levofloxacin 76 96 NHL+PHL+MGH +NOGH Antibiotic Resistance pattern of Klebsiella pneumoniae (2013) Antibiotics Resistance rate (%) Number of tested isolates Surveillance site Cefotaxime 38 164 NHL+PHL+NOGH+ MGH Ceftriaxone 52 210 NHL+PHL+NOGH+ MGH Ceftazidime 62 133 NHL+PHL+NOGH+ MGH CTX, CAZ, CRO 58 26 NHL+NOGH Imipenem 0 25 NHL Antibiotic Resistance rate of MRSA (2013) Antibiotics Resistance rate (%) Number of tested isolates Surveillance site MRSA 8 573 NHL MRSA 5 20 NOGH 15 April 2016 Governance • Does the country have a comprehensive plan on AMR – Yes (processing) • Has a national focal point for AMR been designated – Yes, Director (Laboratories) • Has a national multisectoral steering committee for AMR been constituted – Plan in 2016 • Is a national programme for surveillance of AMR operational in country - Yes (processing) National capacity for AMR • Are majority of lab competent to ascertain AMR using standard methodology – Yes • National network for surveillance of AMR through quality laboratory services? – Not yet • Is there a mechanism for data collection and analyses at national level / use of WHONET. – Use of WHONET : only in YGH – National Health Laboratory started to collect monthly paper report on antimicrobial resistance from central and State/Regional hospitals in 2015. • Are educational activities for prescribers undertaken – No • Is there a system of prescription audit at tertiary care hospital – No • National Hospital Accreditation schemes with rational use of antimicrobials as an essential requirement for accreditation – still trying Regulatory mechanisms for AMR • Is there a legislation that regulates the production, distribution, sale and prescription of antimicrobial agents - FDA • Legislations banning over the counter sale of selected antimicrobial agents – No • Hospitals in the public and private sector in country with a policy for rational use of antimicrobials - No • Is there a national policy for antibiotic use in humans – Plan to start in 2016 • Is there a national policy for antibiotic use in animals - No • Are national treatment guidelines for infectious diseases available - TB, HIV, Malaria, Leprosy Community Empowerment • Have some educational products/material developed for communities? – Radio, Television, Newspaper, Journals, Posters, Pamphlets, etc. • Have some campaigns been launched for creating awareness amongst communities - Yes • Is there any programme to educate school children on AMR - No 15 April 2016 Research on AMR • Any research being supported to develop new antibiotics? – No • The operational research projects on AMR that are being supported – No • Publications on AMR – Bloodstream infections at a tertiary referral hospital in Yangon, Myanmar. Trans R Soc Trop Med Hyg (2014) 108 (11) – Virulence Factors and Genetic Characteristics of Methicillin-Resistant and –Susceptible Staphylococcus aureus isolates in Myanmar. Microbial Drug Resistance. Volume 17,Number 4, 2011 Major issues in combating AMR • For establishment of a national multi-sectoral coordination mechanism for prevention and control of anti- microbial resistance (AMR) • To develop a national surveillance mechanism of AMR and need to establish laboratory- based networks for the surveillance of antimicrobial resistance • Monitoring of antibiotic use and strengthening rational use of anti-biotic. THANK YOUThank You 15 April 2016 The Philippine Action Plan to Combat AMR – One Health Approach •National action plan developed by the Inter- Agency Committee on AMR as mandated by a national policy issuance signed by the Office of the President in 2014 •Officially launched last Nov 2015 in a multi-stakeholder national AMR Summit in celebration of the 2015World Antibiotics Awareness Week Key challenges to start development of NAP on AMR with One Health approach • Absence of a specific law that would provide a clear and integrated direction and action against AMR in both humans and animals. • Fragmented policies and programs on surveillance & laboratory capacity, drug accessibility and quality, rational use of medicines, infection prevention & control, and research and development • Absence of a designated and accountable agency tasked to oversee, integrate and organize all efforts to combat AMR • Low awareness on the threats of AMR Governance of AMR • AO 42 series of 2014 – Creation of an Inter-Agency Committee for the Formulation and Implementation of a Nat Action Plan to Combat AMR in the Philippines Co Chairs: Dept of Health and Dept of Agriculture Members: Dept of Trade and Industry, Dept of Interior and Local Govt, Dept of Science and Technology • Key Stakeholders - Other Government Sectors: Dept of Education, Commission on Higher Education - Academe: association of deans, national student groups - Professional Societies: Professional Regulatory Boards and med societies - Civil Societies and Patient Organizations: Med Transparency Alliance, Phil Assoc of Patient Organizations - Pharmaceutical Industry organizations • Aligned with the Global and Regional Agenda to combat AMR • High level accountability (involvement of OP and Ministers involved) • National priority agenda • Multi-sectoral strategic planning • Clear timelines, targets, responsible agencies and costing for every activity • Budgetary requirements for identified activities are included in the work and financial plans of the responsible agencies • Indicators for M&E • Stakeholder engagement for the implementation of the plan supported by a manifesto of support from stakeholders The Philippine Action Plan to Combat AMR – One Health Approach •Output indicators for activities in the action plan •Outcome indicators to monitor the rational prescribing, dispensing and use among human health and vet professionals, the farmers and fisher folks, and the public/patients •Impact: set AMR rates targets Accountability and Transparency 15 April 2016 Accountability and Transparency HUMAN HEALTH - OUTOME INDICATORS Target Stakeholder Objective Indicators Prescribers To ensure rational prescribing of antimicrobials by ensuring that treatment selection is evidence-based 1. % of physicians who are compliant to CPGs and National Antibiotic Guidelines 2. % of physicians who prescribe definitive treatment based on antibiograms Pharmacists To ensure rational dispensing of antimicrobials by ensuring that antimicrobials are only dispensed with prescription 3. % of Antibiotics transaction sold/dispensed without prescription Patients/ Household To ensure responsible use of antimicrobials through improved practices and attitudes on the use of antimicrobials 4. % of Patients taking antibiotics for cough and colds 5. % of Patients taking antibiotics that have been kept at home without consulting a doctor 6. % of Patients who completely finishes prescribed antibiotics Hospitals/ Health Facilities To ensure procurement of antimicrobials based on the national formulary restrictions. 7. % of Government hospitals/ health facilities that procures based on the national formulary guidelines To ensure that proper use of antibiotics according to the DOH National Antibiotic Guidelines (NAG). 8. % of hospital implementing or adopting the DOH NAG 9. % of hospitals with existing restriction policies for highly reserved antibiotics ANIMAL HEALTH INDICATORS Practitioners To ensure rational prescribing of antimicrobials by ensuring that treatment selection is evidence-based. 1. % of practitioners who prescribe treatment based on laboratory test 2. % of practitioners who require the conduct of clinical examination prior to issuance of prescriptions 3. % of practitioners who prescribe based on historical case 4. % of practitioners who are compliant to guidelines on rational use of veterinary drugs 5. % of practitioners who prescribe based on current situation 6. % of practitioners who recommend withdrawal period 7. % of practitioners with effective treatment 8. % of practitioners with failure treatment Suppliers/ Store Owners To ensure rational dispensing of antimicrobials by ensuring that antimicrobials are only dispensed with prescription. 9. % of antibiotics sold without prescription 10.% of suppliers with licensed veterinarian Farmers/ Fisher folks To ensure responsible use of antimicrobials through improved practices and attitudes on the use of antimicrobials. 11. % of farmers/fisher folks that administer antibiotics to animal with prescription from veterinarian 12. % of farmers/fisher folks that administer antibiotics to animal without prescription from veterinarian 13. % of farmers/fisher folks that administer antibiotics based on experience 14. % of farmers/fisher folks that religiously follow dosage prescribed by the veterinarian or completely finishes prescribed antibiotics to animals 15. % of farmers/fisher folks who buy antibiotics without prescription 16. % of farmers/fisher folks who follow withdrawal period 17. % of farmers/fisher folks with effective/successful treatment 18. % of farmers/fisher folks with failure in treatment • High level commitment and leadership (eg, AO 42 s 2014) • Platforms/venues for sharing and collaboration (eg, ICAMR, National AMR Summit) • Evidence-based communication plan– advocacy and lectures backed up by evidences (Country Situation Analysis on AMR Report, ARSP data); targeted messages Key success factors for effective communication, collaboration and actions across sectors Next Steps • Antibiotic Stewardship Program (as part of the health facilities licensing standards) • Strengthen the implementation of IPC and surveillance of healthcare-associated infections in hospitals • AMR Surveillance in Animals • Integrated surveillance on AMR surveillance and antibiotic use both in the human and animal sector • Publication of National Antibiotic Guidelines • Incorporation of AMR and RUM principles in health and vet professionals education components of school curricula and adult education programs and in continuing professional education programs of health professionals. • Localize and targeted campaigns/ advocacy Programs/ Activities • Strengthen monitoring on compliance to no-prescription-no-dispensing policy Instructions • Please use maximum 6 slides in total, only • Please keep the length of the presentation to max. 7-8 min. to allow time for questions i.e. maximum 10 minutes / country including questions • Objective of the presentation is to discuss and identify good practices in the development and implementation of national action plans on AMR • We would like you to focus of sharing experiences on successful governance mechanisms or your plans on how the country will move forward the AMR agenda with the One Health approach • Please do not spend too much times on describing details of country situation or the national action plan, but do share relevant publication and documents electronically so we can distribute such publications in the meeting on a USB Suggested content of country presentation Slide 1 • Introduction, background • Current status of National Action Plan on AMR i.e. not yet exists, under development ; launched ,but not yet implemented ; launched and actively implemented Slide 2 • Key challenges to start development of national action plan (NAP) on AMR with One Health approach, Slide 3 • Who are the key stakeholders? • Current governance and oversight structures / processes to bring together various sectors Slide 4 • Main achievements or Plans for : a) Strategic planning; b) operational planning; budgeting and financing implementation of NAP Slide 5 • Accountability and transparency: mechanism for monitoring and evaluation of progress of implementation Slida 6 •Lessons learnt: Key success factor for effective communication, collaboration and actions across sectors •Next steps 15 April 2016 Multi-Sectoral Action Plans in Korea Kim Yong-Sang DVM, Ph. D. Director of Animal Health Management Division, Ministry of Agriculture, Food and Rural Affairs, KOREA B-Regional Technical Consultation on Antimicrobial Resistance in Asia Four Key Activities 1. Strengthening the surveillance system that monitor antibiotic usage and resistance 2. Promoting the appropriate use of antibiotics 3. Supporting the reducing of incidence of infection 4. Strengthening working with interministerial and international level. Strengthening the surveillance system
Goals • To provide important data for identification of resistance problems and risk analysis • To identify the contributing factors for the development and spread of resistance Strengthening the surveillance system Current <In human medicine> • Monitoring 6 major MDROs (Multi-Drug Resistant Organisms) incidence in 100 healthcare facilities since 2011 • In laboratory surveillance, we monitor major pathogens of healt hcare associated infection and Enterobacteriaceae, and publish annual report named KARMS (Korean Antimicrobial Resistance Monitoring System) <In veterinary medicine> • Monitoring the resistance on indicator, foodborne pathogens, and animals pathogens in animals and animal products since 2003, names KVARMS (Korean Veterinary Antimicrobial Resistance Monitoring System) 항생제 판매 및 내성 모니터링 체계 Local Vet. Service Food and Drug Administration Korean Animal Health Product Association Local Vet. Service Consumption Animals Carcasses Retail meats Imported meats Animal & Plant Quarantine Agency Isolates Isolates Annual report data data data data Distribution (Homepage) Food and Drug Administration KVARMS (Korean Veterinary Antimicrobial Resistance System) Strengthening the surveillance system
Next steps • Building a portal system encompassing human, veterinary, food as well as environment sectors in order to build a management foundation for the one health approach • Expanding monitoring in area of food production chain, fisheries and environment • Harmonizing with surveillance system at local and national levels as well as at the global level 15 April 2016 Promoting the appropriate use of antibiotics in animals
Goal • To ensure safe use and to minimize the development of resistance
Current • Total ban on all antibiotics for Growth promoters in animal feed in 2011 • Implementation of Vet. Prescription gradually on animal drugs in 2013 Phase-out of antibiotics for growth promoters •1997-2003 : avoparcin, spiramycin, olaquniodox, spectinomycin, flubendazol etc • 2005. 05 (53→25) : Oxytetracycline HCl, Erythromycin, Sulfadimethoxine etc • 2009.01 (25→18) : Oxytetracycline, Chlortetracycline, Bacitracin zinc, Colistin sulfate, Lincomycin hydrochloride, Neomycin sulfate, Penicillin • July 2011 (18→9) (remaining 9 all inophores(antic-coccidiosis) : apramycin, avilamycin, bambermycin, bacitracin methylene disalicylate , enramycin, tiamulin, tylosin, virginiamycin, sulfathiazole • Overall consumption of antibiotics in food producing animals has been decreased by around 30%, from 1,550 tons in 2005 to 1,000 tons in 2014 • Consumption and resistance of antibiotics for feed additives, such as tetracyclines, penicillins, and sulfonamides, has gradually decreased • But, therapeutic usage and resistance of some antibiotics such as cephalosporins and phenicols, has been increased(1.5 times) Consequence of phase-out • Introduction of veterinary prescription on animal drug in August 2013. • Policy of veterinary prescription is being implemented by three stage during 2013-2018 • Critically important antimicrobials used for humans are applied for vet. prescription by priority. • First stage, macrolides, 3rd & 4th generation cephalosporins, and fluoroquinolones were included (in total 21 drugs) • Second and third stages will start in 2016 and 2018, respectively. Veterinary prescription Promoting the appropriate use of antibiotics in animals
Next steps • Expanding all antibiotics for Vet. Prescription • Developing the antibiotic use guidelines for each animal species • Promoting education and training on prudent use in animals Supporting the reducing incidence of Infection
Goal • Minimizing the use of antibiotics in human and animal by supporting the reducing of incidence of infection 15 April 2016 Supporting the reducing incidence of Infection
In human medicine Current • Enacted HAI (Healthcare‐associated infection) prevention activities by the Medical law in 2002 • Induce incentives for AMR control efforts of hospitals ex) antibiotic stewardship and participation in AMR surveillance • Develop standard infection prevention guidelines Next Step • Expanding the organization's infection control personnel by medical laws reform • Supporting infection control consulting and also supporting operating the regional network for small and medium hospitals • Enhancing education and training of standard guideline Supporting the reducing incidence of Infection
In Veterinary medicine Current • Encourages Good Animal Practices such as HACCP and Animal Welfare • Promotes the creation of environment that reduce the need for antibiotics • Implements guidelines for prevention of disease Next steps • Expanding the environment-friendly farming systems • Implementing effective infection prevention and control measures • Developing new vaccines associated with outbreaks of animal diseases Strengthening working with interministerial & international level
Goals • To enhance ability to detect AMR, to share data on the antibiotic use and AMR • To prevent and control of emergence and spread of antibiotic resistance Strengthening working with interministerial & international level
Current • In domestic level, an interministerial antibiotic resistance working group was established in 2015. Meetings are held regularly to discuss current and planned measures and shared projects • In international level, the government has been joining meetings held by WHO, FAO, and OIE • Joined the Global health security agenda as a contributing country in the area of antimicrobial resistance in 2015. Strengthening working with interministerial & international level
Next steps • Strengthening the network with relevant departments in area of monitoring and research • Supporting continuous implementation in area of monitoring and surveillance of global action plan 18 Thank you for your attention !! 15 April 2016 Governance mechanism to implement National Action Plan on AMR Thailand Dr. Nithima Sumpradit Food and Drug Administration, Ministry of Public Health Secretary team, AMR Coordination and Integration Committee Milestones: Development of national action plan on AMR 2016-2018 2014 2015 2016 • UNGA National action plan* (MOH & MOA) National agenda* [Political commitment] (MOH, MOA & NHA |AMR-CIC) NHA - social mechanism to facilitate public policy making with inclusive participation: government , academia, private and people sectors across all 77 provinces of Thailand. * Ongoing activities • WHA 67: Develop GAP MOH Leadership & teamwork Engage stakeholders Know your landscape MOH Leadership • WHA 68: Adopt GAP • Alliance of Champions AMR-CIC & NHA collaboration AMR Coordination & Integration Committee (AMR-CIC) National Health Assembly (NHA) (Draft) Strategic framework Thailand’s action plan on AMR 2016 – 2018 Guiding principles: Action-oriented; Orchestrated & synergistic collaboration; Political commitment Mission To establish infrastructure and consolidate multi-sectoral collaboration to resolve AMR sustainably Agriculture Community Hospital Strategic issues 1 AMR surveillance (One Health) 2 AMU surveillance & distribution control 3 IPC & Antimicrobial stewardship in hospital 4 AMR control & antimicrobial use in agriculture/ pet 5 Public awareness 6 Governance structure /mechanism, M&E, international collaboration Vision Reduction of negative impacts caused by AMR Underlying concepts: One Health; Triangle that moves the mountain; GAP-AMR Note: Modified version from AMR Coordination and integration Committee Strategic issue 6: Governance structure/ mechanism, M&E and international collaboration Proposals to the cabinet 1. Approve National Action Plan & accelerate its implementation 2. Establish the National Multisectoral Committee on AMR (under the regulation of Office of Prime Minister) 2.1 Advocate AMR toward National Agenda 2.2 M&E of national action plan implementation 2.3 Develop mechanisms to link global & national policies 2.4 Develop and update the annual AMR action report Lessons learned Development of national action plan on AMR • Don’t make it a stand-alone policy • Do reconcile different interests and expectations • Do assign ‘authority agency’ to each strategic issue • Do make the use of ‘outside-in’ momentum • Do have champions at all levels What’s next? • National level – National Action Plan on AMR by 2016 – Key initiatives (to be started in 2016) • AMR surveillance | GLASS implementation • AMU surveillance | Track and trace the production, importation and distribution of antimicrobials for human and animal use • Regulation & Enforcement | Antibiotics as prescription drugs • International level – Engage and support global efforts on combating AMR 15 April 2016 Medical Service Administration Ministry of Health of Vietnam The implementation of national action plan on Antimicrobial resistance in Vietnam Population: 89 millions Square: 330.972 km2 Central hosp.: 42 Provincial , district hosp.: 1034 Others hosp.: 20 MoH (MSA) • 42 MoH's hospitals • 27.255 beds • 11,6 % total beds • 614 District Hospitals • 71.711 beds • 30,4% • 420 Provincial Hospitals • 117.116 beds • 49.7% MINISTRY OF HEALTH 63 PROVINCIAL DEPARTMENT 614 DISTRICT HEALTH BUREAU Tertiary Secondary • 11.000 Commune Health Centre Primary care 11.000 COMMUNITIES First Medical Referral PUBLIC HOSPITAL NETWORK The Minister of Health approved the National action plan on AMR from 2013 to 2020 (June 21, 2013) NATIONAL ACTION PLAN This is comprehensive, overall, long-term strategy
Raise awareness of community and health workers on antimicrobial resistance
Strengthen, improve national surveillance system on the use of antibiotics and AMR surveillance
Ensure adequate supply of quality medicines
Promote rational use of medicines
Promote infection control
Promote rational use of antibiotics in agriculture, animal health OBJECTIVES INFORMATION, EDUCATION AND COMMUNICATION TECHNICAL EXPERTISE AND TRAINING FINANCE SCIENTIFIC RESEARCH AND INTERNATIONAL COOPERATION SOLUTIONS 15 April 2016 Signing commitment multisectoral to combat antimicrobial resistance in Vietnam
Raising awareness of community and health workers on antibiotic and AMR Organizing news conference; workshop; Developing communication materials (brochures, standees, posters, radio messages, TV messages video, etc) Pledging use antibiotics responsibly from central to district level IMPLEMENTATION
Strengthen legal regulations and professional guideline: Guideline on antibiotic use; Standard treatment guidelines in specialties; Guidelines for implementing antibiotic stewardship program in hospitals; Circular on functions and duties of microbiological laboratories in hospital
Promoting infection control in hospital IMPLEMENTATION 11 Resources such as human, finance, infrastructure are limited. Prevention and control of infectious diseases are ineffective Drug quality hasn’t been controlled well The AMR surveillance system hasn’t been etablished. Prescription is inappropriate Awareness on AMR is limited CHALLENGES 12  Mechanism collaboration between MoH with development partners and ministries (ministry of agriculture and rural development, ministry of industry and trade, ministry of resources and environment) hasn’t been etablished yet.  There are not national database on antibiotic use and AMR yet  Use of antibiotics in agriculture, animal health hasn’t been controlled closely CHALLENGES 15 April 2016
Mobilizing funds for AMR
Focus on priority activities for AMR Continuing to raise awareness of community and healthcare professionals on AMR Developing national database on antibiotic and AMR Etablishing national AMR surveillance system Collaboration closely with partners and ministries to combat AMR NEXT STEPS Thank you for your attention! 15 April 2016 April 20161 | Monitoring Considerations AMR National Action Plans Tokyo 15 April 2016 Keiji Fukuda April 20162 | Overview
Measuring progress against AMR essential for success & future support
Following adoption of GAP, monitoring & reporting on its implementation now widely anticipated – Member states – Donors – Organizations
Discussion & planning underway on how to do this April 20163 | Overview
Assessing & reporting global & regional progress depends on monitoring implementation of national action plans
What do people want to know? – Is progress being made against national targets – Constraints – Areas needing course correction & support Country Regional Global April 20164 | General considerations
As a management tool, M&E systems should facilitate – Assessment & decision making – Resource allocation
As a real-world challenge, M&E systems should build on existing systems & work towards harmonization – Health, agriculture & veterinary systems – Regional systems April 20165 | General considerations
Ideally, indicators should – Be well-defined & measurable – As few as possible – Draw upon existing indicators & data sources
Strong IT systems critical for data entry & access
Report results backwards - in user friendly format - essential for sustained support April 20166 | Examples: what might be monitored?
No. of countries with AMR National Action Plan
Progress against strategic objectives – Awareness; Education & professional development; AMR surveillance & reporting; preventive measures etc
Strengthening of veterinary services
Impact – Changes in levels of resistance – Levels of antimicrobial use in humans & animals 15 April 2016 April 20167 | Using existing data sources & monitoring systems has major benefits
Communication
Co-ordination
Efficiency
Minimize transaction costs & duplication
Buy-in AMR monitoringIHR system Facility surveys Health information system Water & sanitation monitoring SDG monitoring April 20168 | Example: Assessment of International Health Regulations (IHR) capacities
Country self-assessment done annually
Joint external evaluations every 4 years (starting)
Provides standardized global rating of capacity Progress Level Objective 1: Raising awareness and understanding No capacity Government not involved in awareness-raising activities on antibiotic resistance Limited capacity Some government-led activities in parts of the country to raise awareness about antibiotic resistance and actions to address it Developed Capacity Nationwide, government-led antibiotic awareness campaign targeting the general public Demonstrated capacity Nationwide, government-led antibiotic awareness campaign targeting specific groups (e.g. doctors, pharmacists, nurses, drug sellers) Sustainable capacity Focused, national scale activities to change behaviour in target groups in human and animal health, public and private sectors. Monitoring of awareness and behaviour change in last 5 years. April 20169 | Current draft concept for monitoring Global Action Plan Inputs Activities/Outputs Outcomes Impact Goal Country stakeholder engagement Develop & implement national AMR plans Better data on prevalence, AM use and resistance WHO support & guidance Surveillance of resistance, infections and consumption Behaviour changes in antibiotic demand (in health & food chain) FAO & OIE guidance & standards Raise awareness of policy makers, farmers, vet & health workers, public Appropriate prescribing of AMs by professionals (health workers, vets) More appropriate consumption of antibiotics Effective & safe medicines are available for infectious diseases Other international & national partners’ action AM stewardship, regulation, treatment guidelines AMs available are of assured quality, on approved list Slower development of resistance Funding Infection Prevention & Control in facilities & community Lower incidence of infection in health facilities; higher WASH and vaccine coverage Technical expertise & support R&D incentives, R&D Facility, funding, coordination Increased R&D related to priority infections inc diagnostics, vaccines, medicines New medicines, diagnostics and vaccines developed April 201610 | Concluding Points
Monitoring is essential
Major challenge to find an approach that – Provides a coherent global – regional picture – Is useable across sectors – Is nationally & locally relevant & desirable – Is simple, practical & sustainable 15 April 2016 Roadmap for Action on Antimicrobial Resistance Combating Antimicrobial Resistance: Public Health Challenge and Priority New Delhi Meeting, 23-25 Feb. 2016 Overview • AMR is an issue of urgency for public health all over the world • complex and needs concerted actions across all sectors • In 2011, Jaipur Declaration with a follow-up in 2014 • In 2015, 68th WHA resolution: • Global Action Plan (GAP) for AMR adopted • MS’ commitment to develop National Action Plan (NAP) aligned with GAP-AMR by May 2017 • WHO is to report on the development, implementation, monitoring and evaluation of NAP-AMR and GAP-AMR. • Global commitment will be formalised through a series of high-level meetings - G7, UNGA • Delhi Meeting to consolidate action from global to national – through a roadmap Goal of the Roadmap • Develop and implement the National Action Plan on AMR with the following priority areas of action : • Improve awareness and understanding of AMR; • Strengthen surveillance in human health, animal health and agriculture sectors • Strengthen infection prevention and control (IPC) practices in healthcare facilities; • Promoting rational use of antimicrobials across sectors; and • Promoting investments in AMR and related research Development/implementation of NAP • Action from countries: • Nodal Institution for AMR designated ASAP • Create a coordination mechanism applying the One-Health approach body involving: • Agricultural and environmental sectors of government • Partners from the civil society organizations (industry associations, professional organizations, association and private sectors) • For a holistic/comprehensive approach • Review to identify challenges and needs in 2016 • National Action Plan should be aligned with GAP-AMR by May 2017 • Timeline of deliverables in NAP will be as appropriate to each country’s context and circumstances • Develop comprehensive policies that cover all pillars of the Global Action Plan for AMR Development/implementation of NAP Action from WHO: • Tools to review challenges and needs ready by March 2016 • Technical support to develop NAP made available: • Workshops on development NAP • Country-specific technical supports • Support implementation of NAP Roadmap for Development of a National Action Plan for AMR • Nodal Institution on AMR • Functional multi-sectoral coordination body (e.g. AMR Committee) • Review challenges and needs to identify gaps and opportunities • Develop the National Action Plan: • Should address several Priority Action Areas • Should focus on comprehensive multisectoral approach • Should embed Monitoring and Evaluation indicators with time bound deliverables as appropriate to country context • NAP to be owned across Ministries and sectors • Implementation of NAP can build on already existing structures/activities 15 April 2016 Priority Action Areas in the National Action Plans for AMR PAA #1: Awareness and Understanding of AMR • Action by countries: • Promote AMR awareness that leads to behavior change • Strengthen collaboration among all stakeholders for a synergistic approach • Formulate a One-Health approach at national and subnational levels; • Encourage continuing professional education on AMR among relevant professionals • Deliverables: 1. Coordinated action for applying One-Health approach 2. Improved emphasis of AMR on professional curriculum and CPE/CME 3. Awareness campaign strategies towards the public and for the health professionals in place PAA #2: Surveillance in Humans, Animals and Agriculture Action by countries: • Consider voluntary participation in Global Antimicrobial Surveillance System • Strengthen AMR surveillance in humans at sentinel sites with coordinated data use and analysis at central level. • Encourage research using surveillance data • Develop AMR surveillance in humans, animals and agriculture in a harmonized manner Deliverables: 1. AMR Surveillance system in place and functional 2. Attempt to develop a model of surveillance in human health, animal health, and agriculture sector as appropriate for each country PAA #3: Infection Control in Healthcare Facilities Action by countries: • Develop national guidelines for each level of healthcare facility at national and sub-national levels; • Establish IPC focal persons within Ministry to enable effective implementation of guidelines • Link IPC programs and surveillance of AMR and HAIs. Deliverables: 1. IPC guidelines introduced 2. IPC focal persons for guidelines nominated 3. Models formulated for linking IPC program and surveillance of AMR and HAIs PAA #4: Rational Use of Antimicrobials across all Sectors Action by countries: • Strengthen regulations to ensure access to quality, safe, affordable and efficacious antimicrobials • Prohibit sale of antimicrobials without prescription • Establish evidence-based treatment guidelines • Develop facility and community based programs for rational use of antimicrobials • Encourage surveys of antimicrobial use as appropriate Deliverables: 1. Regulations in place for sale and prescription of antimicrobials 2. evidence-based treatment guidelines published and disseminated 3. Introduce programs for rational use of antimicrobials in health facilities and communities PAA #5: Investments on AMR and related research Action by countries: • Assess the needs for investment of national plans for AMR • Determine AMR research priorities • Create an enabling environment that fosters cooperation for research and innovations Deliverables: 1. Policies that allow sustained environment for research and innovations 2. Evidence of burden of AMR and cost-benefits studies for action available 15 April 2016 WHO’s Role in Support of Roadmap • Monitoring progress and publishing progress reports on AMR status in each MS • Advocacy: • For the Global AMR Surveillance system (GLASS) • Integrated surveillance of AMR in humans, animals and the environment • Capacity-building and Technical Assistance for: • Policy development and development/implementation of NAP, • Data quality assurance; • Analysis, interpretation and dissemination of results • Support resource mobilization and leveraging other resources from other partners. Conclusions • Development of NAP is paramount to address a complex issue it provides • Strategic approach • Coordinated action • NAP is only the beginning: • NAP developed based on gaps and needs • NAP should be complemented by time-bound deliverables • NAP will be continuously improved thru a dynamic process of action-monitoring-adjustment-action 15 April 2016 Importance of robust surveillance system across Asia Keigo Shibayama National Institute of Infectious Diseases Japan AMR Surveillance Continuous, systematic collection, analysis and interpretation of AMR-related data. Monitoring and clarifying the epidemiology of AMR. Useful for planning, implementation, and evaluation of practice 0 5 10 15 20 25 30 35 200120022003200420052006 0% 10% 20% 30% 40% 2007200820092010201120122013 IPM AMK CTX CAZ LVFX Japan’s experience on robust AMR surveillance Total Antimicrobial-Resistant Bacterial Infections Division SSI Division ICU Division NICU Division Clinical Laboratory Division New participants are recruited every year. Number of participating hospitals Approximately 1,800 hospitals are participating Japan Nosocomial Infections Surveillance JANIS format data Convert all electrical data to JANIS format National Institute of Infectious Diseases Compile data from all hospitals Analyze and publish information periodically Clinical laboratory in participating hospitals Data collection 5 Data submission Numbers of isolates cultured at participating hospitals Samples No of samples No of culture- positive samples No of cultured isolates Respiratory tract 1,488,882 942,330 1,978,204 Urine 621,446 325,947 497,438 Stool 401,659 198,141 392,408 Blood 1,562,028 200,174 226,460 Spinal fluid 63,505 3,262 3,633 Others 1,000,110 460,798 817,695 Total 5,137,630 2,130,652 3,915,838 Open report 2014 15 April 2016 7．Antimicrobial Susceptibility of Major Bacteria* Escherichia coli† 112,811 (62.2%) 186,940 (99.6%) 146,205 (99.8%) 165,979 (99.9%) 121,420 (83.7%) 111,871 (85.5%) 168,872 (90.3%) 111,705 (78.3%) 129,891 (69.8%) 86,923 (96.6%) 95,963 (53.8%) 85,519 (49.3%) SorI:24 (0.0%) SorI:1 (0.0%) SorI:1 (0.0%) SorI:1 (0.0%) I:2,638 (1.5%) I:475 (0.3%) I:58 (0.0%) I:13 (0.0%) I:5,203 (3.6%) I:1,798 (1.4%) I:5,803 (3.1%) I:1,974 (1.4%) I:4,066 (2.2%) I:1,436 (1.6%) I:5,644 (3.2%) I:1,647 (0.9%) IorR:420 (0.2%) IorR:3 (0.0%) IorR:4 (0.0%) IorR:1 (0.0%) IorR:8,763 (6.0%) IorR:308 (0.2%) IorR:5,310 (2.8%) IorR:237 (0.2%) IorR:662 (0.4%) IorR:19 (0.0%) IorR:719 (0.4%) IorR:438 (0.3%) 65,593 (36.1%) R:311 (0.2%) R:107 (0.1%) R:62 (0.0%) R:9,649 (6.6%) 16,849 (12.9%) R:7,013 (3.7%) 17,920 (12.6%) 50,832 (27.3%) R:1,573 (1.7%) 75,795 (42.5%) 85,516 (49.3%) ND:15 (0.0%) ND:84 (0.1%) ND:46 (0.0%) ND:97 (0.1%) ND:82 (0.1%) ND:23 (0.0%) 10,756 (7.5%) ND:717 (0.4%) ND:1 (0.0%) ND:98 (0.1%) ND:406 (0.2%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ABPC (N=173,526) PIPC (N=178,219) TAZ/PIPC (N=89,953) CEZ (N=186,169) CTX (N=142,592) CAZ (N=187,022) CFPM (N=130,908) AZT (N=145,132) IPM (N=166,125) MEPM (N=146,458) AMK (N=187,744) LVFX (N=181,462) S : Susceptible S or I : Susceptible or Intermediate I : Intermediate I or R : Intermediate or Resistant R : Resistant ND : Not determined Annual Open Report 2014 (All Facilities) Inpatient specimens with MIC values reported by either the broth microdilution method or Etest are counted. Duplicates based on the result of Antimicrobial Susceptibility Testing are not recounted within 30 days (See Appendix). * Results are interpreted according to the CLSI2007 (M100-S17) criteria. †E. coli corresponds to Isolated Bacterial Codes 2001-2007. 21 This Open Report does not cover every data from facilities nationwide. June 10, 2015 March 31, 2016Date of Publication (English Version) : Japan Nosocomial Infections Surveillance (JANIS) 【CLSI2007 Version】 Clinical Laboratory Division Date of Total Tabulation : 0 5 10 15 20 25 30 35 2001 2002 2003 2004 2005 2006 % % CTX LVFX CAZ 0% 5% 10% 15% 20% 25% 30% 35% 40% 2007 2008 2009 2010 2011 2012 2013 IPM AMK CTX CAZ LVFX IPM Antimicrobial resistant E. coli Rates of E. coli non-susceptibility to clinically important antimicrobial drugs JANIS Annual Reports 2001–2013 CLSI 2007 Other species MSSA MRSA Staphylococcus epidermidis Streptococcus pneumoniae Streptococcus pyogenes Streptococcus agalactiae Enterococcus faecium Enterococcus faecalis Enterobacter cloacae Enterobacter aerogenes Proteus mirabilis Proteus vulgaris Citrobacter freundii Citrobacter koseri Serratia marcescens Pseudomonas aeruginosa Acinetobacter spp. Haemophilus influenzae Regional data National data Fukuoka Prefecture Prevalence of Vancomycin resistant Enterococcus faecium (VRE) is higher in Fukuoka. http://www.nih-janis.jp/english/index.asp Publication of Open report National data Hospital B An example of an antibiogram of a hospital where an MDR A. baumannii outbreak took place 15 April 2016 International Cooperation AMR Surveillance Capacity Development JANIS analytic platform is available to any countries. The program is compatible with WHONET. Hospitals National Public Health Institute in Asian countries JANIS platform MoH Production of Report Development of AMR surveillance Data format is open to public. Antimicrobial Code Ver5.0 Code Drug Name 1100; Monobactams 1101 Aztreonam 1106 Carumonam 1200; Penicillins 1201 Benzylpenicillin 1202 Phenoxymethylpenicillin 1206 Benzylpenicillin Benzathine 1207 Methicillin 1208 Oxacillin 1211 Phenethicillin Potassium 1212 Cloxacillin 1213 Dicloxacillin 1214 Flucloxacillin 1216 Ampicillin 1217 Hetacillin 1221 Bacampicillin 1222 Mezlocillin 1226 Talampicillin Hydrochloride 1231 Sultamicillin Tosylate 1236 Lenampicillin 1241 Ciclacillin 1246 Amoxicillin 1251 Aspoxicillin 1252 Carbenicillin 1256 Sulbenicillin 1257 Carindacillin 1258 Carfecillin 1260 Mecillinam 1261 Pivmecillinam 1266 Piperacillin 1267 Ticarcillin 1271 Clavulanate/Amoxicillin 1276 Clavulanate/Ticarcillin 1281 Sulbactam/Ampicillin 1282 Tazobactam/Piperacillin 1286 Cloxacillin + Ampicillin 1291 Dicloxacillin + Ampicillin 1300; Penems 1301 Faropenem 1306 Ritipenem Acoxil 1400; Carbapenems 1401 Imipenem/Cilastatin 1406 Panipenem/Betamipron 1411 Meropenem Trihydrate 1416 Biapenem 1421 Doripenem Hydrate 1426 Tebipenem Pivoxil 1450; Carbacephems 1451 Loracarbef 1500; Cephems 1501 Cefradine 1502 Cefaloglycin 1506 Cephalexin 1511 Cefatrizine 1516 Cefroxadine 1521 Cefaclor 1526 Cefadroxil 1531 Cephaloridine ・ ・ ・ ・ Specimen Source Code Ver1.0 Code Name 100; Oral/Endotracheal/Respiratory 101 Sputum 102 Endotracheal aspirate 103 Bronchoalveolar lavage 104 Throat 105 Nasal 106 Oral 107 Lung biopsy 109 Other （Respiratory) 200; Urinary/Genital 201 Urine 202 Urine collected by catheter 203 Urine obtained from indwelling catheter 204 Urethral discharge 205 Vaginal discharge 206 Catheterized urine 209 Other (Urinary/Genital) 300; Digestive 301 Feces 302 Gastric/Duodenal aspirate 303 Bile 304 Gastrointestinal biopsy 309 Other (Gastrointestinal) 400; Blood/Fluid 401 Venous blood 402 Arterial blood 403 Cerebrospinal fluid 404 Pleural effusion 405 Ascites 406 Joint fluid 407 Bone marrow aspirate 408 Pericardial effusion 409 Other (Puncture fluid) 500; Other 501 Ear discharge 502 Eye discharge 503 Skin 504 Decubitus 505 Amniotic fluid 511 Open pus 512 Trapped pus 513 Wound 521 Continuous Ambulatory Peritoneal Dialysis drainage 522 Tip of central venous catheter 523 Catheter insertion site 524 Other catheter specimens 525 Chest tube drainage 526 Chest tube tip 527 Abdominal tube drainage 528 Abdominal tube tip 529 Drain insertion site 530 Other drain specimens 541 Lymph node biopsy 542 Other biopsy/operation materials 999 Other source Isolated Bacterial Code Ver4.1 Code Bacterial Name 1011 Gram-positive cocci 1012 Gram-positive bacilli 1013 Gram-negative cocci 1014 Gram-negative bacilli 1015 Yeasts 1100 Streptococcus sp. 1101 α-Streptococcus 1102 β-Streptococcus 1103 γ-Streptococcus 1111 Streptococcus pyogenes 1114 Streptococcus agalactiae 1117 Group C β-Streptococcus 1120 Group F β-Streptococcus 1123 Group G β-Streptococcus 1131 Streptococcus pneumoniae 1141 Streptococcus mutans 1142 Streptococcus sanguis 1143 Streptococcus mitis 1144 Streptococcus anginosus 1145 Streptococcus intermedius 1146 Streptococcus bovis 1147 Streptococcus salivarius 1148 Streptococcus equinus 1149 Streptococcus uberis 1150 Streptococcus constellatus subsp. constellatus 1151 Streptococcus acidominimus 1200 Enterococcus sp. 1201 Enterococcus faecalis 1202 Enterococcus faecalis (VRE) 1205 Enterococcus faecium 1206 Enterococcus faecium (VRE) 1209 Enterococcus avium 1210 Enterococcus avium (VRE) 1213 Enterococcus durans 1214 Enterococcus gallinarum 1215 Enterococcus casseliflavus 1216 Enterococcus casseliflavus/gallinarum 1217 Enterococcus hirae 1300 Staphylococcus sp. 1301 Staphylococcus aureus subsp. aureus 1303 Staphylococcus aureus (MRSA) 1304 Staphylococcus aureus (MSSA) 1305 Staphylococcus aureus (MSSA) (beta-lactamase non- producing) 1306 Staphylococcus aureus (MSSA) (beta-lactamase producing) 1311 Staphylococcus ,coagulase negative (CNS) 1312 Staphylococcus epidermidis 1313 Staphylococcus saprophyticus subsp. saprophyticus 1314 Staphylococcus hominis subsp. hominis 1315 Staphylococcus warneri 1316 Staphylococcus lentus 1317 Staphylococcus auricularis 1318 Staphylococcus simulans 1319 Staphylococcus cohnii subsp. cohnii 1320 Staphylococcus xylosus 1321 Staphylococcus sciuri subsp. sciuri 1322 Staphylococcus intermedius 1323 Staphylococcus hyicus 1324 Staphylococcus haemolyticus Susceptibility Test Method Code Ver3.0 Code Method Product Name Product Company Notes 11 Broth microdilution method Automated system MicroScan WalkAway Siemens Healthcare Diagnostics 12 Broth microdilution method Automated system Autoscan 4 Siemens Healthcare Diagnostics 16 Broth microdilution method Automated system IS60 (frozen plate) Eiken Chemical 17 Broth microdilution method Automated system IS60 (dry plate) Eiken Chemical 19 Broth microdilution method Automated system ATB Expression bioMérieux 22 Broth microdilution method Automated system BD Phoenix BD Diagnostics 23 Broth microdilution method Automated system VITEK 2 bioMérieux 24 Broth microdilution method Automated system RAISUS Nissui Pharmaceutical 25 Broth microdilution method Automated system 60a (frozen plate) Eiken Chemical 26 Broth microdilution method Automated system 60a (dry plate) Eiken Chemical 27 Broth microdilution method Automated system IA20MIC (frozen plate) Eiken Chemical / Koden Industry 28 Broth microdilution method Automated system IA20MIC (dry plate) Eiken Chemical / Koden Industry 29 Broth microdilution method Automated system IA01MIC (frozen plate) Eiken Chemical / Koden Industry 31 Broth microdilution method Manual Eiken dry plate Eiken Chemical 33 Broth microdilution method Manual Eiken frozen plate Eiken Chemical 34 Broth microdilution method Automated system IA01MIC (dry plate) Eiken Chemical / Koden Industry 35 Broth microdilution method Automated system IA20MIC mkⅡ（frozen plate） Eiken Chemical / Koden Industry 36 Broth microdilution method Automated system IA20MIC mkⅡ（dry plate） Eiken Chemical / Koden Industry 37 Broth microdilution method Automated system IA01MIC mkⅡ（frozen plate） Eiken Chemical / Koden Industry 38 Broth microdilution method Automated system IA01MIC mkⅡ（dry plate） Eiken Chemical / Koden Industry 39 Broth microdilution method Other 41 Gradient diffusion method Manual Etest bioMérieux 45 Broth microdilution method Automated system MIC absorbance determination system (frozen plate) Eiken Chemical MR-5000 etc. 46 Broth microdilution method Automated system MIC absorbance determination system (dry plate) Eiken Chemical MR-5000 etc. 51 Disk diffusion method Manual Sensi-Disc BD Diagnostics 52 Disk diffusion method Manual KB Disk Eiken Chemical 70 Broth microdilution method Automated system RAISUS ANY Nissui Pharmaceutical 71 Broth microdilution method Automated system Dry plate Eiken 192 plate Eiken Chemical 72 Broth microdilution method Automated system IA40i Eiken Chemical 99 Other Data Require ments No. Item Attribute Length * Starting Location Specification B a si c P a ti e n t D a ta M 1 Surveillance Category numeric 1 1 6: international surveillance M 2 Facility Code numeric 5 2 Assigned institutional code M 3 Patient ID alphanumeric 30 7 Encrypted unique ID using 30 single-byte characters 4 Blank space 8 37 S 5 Sex alphabet 1 45 M: Male, F: Female S 6 Date of Birth numeric 8 46 YYYY: year, MM: month, DD: day M 7 Hospital Status numeric 1 54 1: Outpatient, 2: Inpatient S 8 Department numeric 3 55 Refer to "Department Code" S 9 Ward alphanumeric 15 58 Free-text format (alphanumeric only) 10 Blank space 409 73 Sp e ci m e n D a ta M 11 Specimen Source numeric 3 482 Refer to "Specimen Source Code" S 12 Specimen Reception Date numeric 8 485 YYYY: year, MM: month, DD: day M 13 Specimen Collection Date numeric 8 493 YYYY: year, MM: month, DD: day 14 Blank space 13 501 S 15 Bacterial Culture Result 1 or space 1 514 1: negative, space: positive B a ct e ri a l T e st D a ta (M) 16 Isolated Bacterium "A" numeric 4 515 Refer to "Isolated Bacterial Code" (S) 17 Quantification of Bacterial Amount numeric 1 519 1: semi-quantitative analysis, 2: quantitative analysis, 9: others (S) 18 Amount of Bacterium "A" numeric 1 520 1: ≤10^2/ml, 2: 10^3/ml, 3: 10^4/ml, 4: 10^5/ml, 5: 10^6/ml, 6: ≥10^7/ml, 7: 10^3 - 10^4/ml, 8: 10^5 - 10^6/ml 19 Blank space 1 521 (M) 20 Isolated Bacterium "B" numeric 7 522 (M) 24 Isolated Bacterium "C" numeric 7 529 (M) 28 Isolated Bacterium "D" numeric 7 536 (M) 32 Isolated Bacterium "E" numeric 7 543 (M) 36 A-1 Antimicrobial Agent numeric 4 550 Refer to "Antimicrobial Code" (M) 37 A-1 Susceptibility Test Method numeric 2 554 Refer to "Susceptibility Test Method Code" (M) 38 A-1 MIC Sign numeric or space 1 556 1: <, 2: >, 3: ≤, 4: ≥, space: = (M) 39 A-1 MIC Value numeric/period 5 557 XXXXX (right-adjusted integer) or X.XXX (fixed decimal point format) (S) 40 A-1 Zone Diameter numeric 2 562 XXX mm (Integer) (M) 41 A-1 Interpretation (RIS) alphabet 1 564 "R", "I" or "S" (M) 42 A-1 Interpretation (+) numeric 1 565 1: -, 2: +, 3: ++, 4: +++ (M) 43 A-2 to A-50 784 566 (M) 386 B 800 1350 (M) 736 C 800 2150 (M) 1086 D 800 2950 (M) 1436 E 800 3750 O th e r D a ta 1786 Blank space 24 4550 M 1787 Specimen ID alphanumeric/ hyphen 30 4574 Unique ID using 30 single-byte characters 1788 Blank space 1 4604 M 1789 Country Code alphabet 3 4605 Refer to "Country Code" 1790 Blank space 19 4608 M 1791 Version ID alphanumeric/ period 4 4627 Refer to "Summary of JANIS Clinical Laboratory Division (JCLD) Data Submission" 1792 Blank space 50 4631 Format Analysis programs (specifications) are also available for foreign countries. Hospitals in Asian Country National Institute of Infectious Diseases, Japan Preparation of reports (confidential) MoH WPRO is considering to collect and analyze the data and produce report in collaboration with JANIS, if requested. Cooperation with animal sectors 0% 5% 10% 15% 20% 25% 30% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Cefazolin resistance rates of E. coli 採卵鶏 豚 肉用牛 肉用鶏 JANIS 0% 10% 20% 30% 40% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Fluoroquinolone resistance rates of E. coli 採卵鶏 豚 肉用牛 肉用鶏 JANIS（LVFX) Animals Antibiotic food additives Animal antibiotics FoodsThe Environment Human Health One Health One Health Surveillance Network on AMR Human Animals Food Antibiotic use (Under way) One Health Surveillance Council on AMR Current development: One Health Surveillance MHLW Ministry of Health, Labour and Welfare MAFF Ministry of Agriculture, Forestry and Fisheries FSC/CAO Food Safety Commission MOE Ministry of the Environment NIID National Institute of Infectious Diseases NCGM National Center for Global Health and Medicine NVAL National Veterinary Assay Laboratory Environment JANIS JVARM Data link just started JACS (Japan Antimicrobial Consumption Surveillance) Research based Apply One Health Surveillance information to risk assessment and risk management Healthcare-associated Infections surveillance Challenges for developing surveillance system across Asia Laboratory capacity building. Quality control and quality assurance of testing at laboratories. Development of network of hospitals/clinical laboratories at national level Harmonization of surveillance between countries ex. Standardization of protocols and methodologies among countries. Standardization of data format. Harmonization of multisectoral surveillance Genetic analyses required to reveal the linkage of AMR between different sectors Leading to practical AMR control Mentors as well as financial support needed for low-income countries. Organizer needed. 15 April 2016 Panel2: R&D of New Diagnostics and Antimicrobials - Regional Capacities and potential regional mechanisms to stimulate R&D - Moderator Junko Sato, PhD Pharmaceuticals and Medical Devices Agency (PMDA) Japan Background • Antimicrobials have saved millions of lives worldwide, but these drugs are losing their effectiveness because of antimicrobial resistance (AMR). • AMR is present in all parts of the world. New resistance mechanisms emerge and spread globally. • CDC estimates that in the US, more than 2 million people are sickened every year with AMR infections, with 23,000 dying as a result. CDC : The Center for Disease Control and Prevention Background (Cont’) • Patients are dying from AMR infections that used to be treatable. Though new antibiotics are desperately needed, pharmaceutical industries are withdrawing from the antibiotics market because of the low return on investment and the difficult regulatory environment. • Several Initiative are established as global efforts to foster development innovative antimicrobials. Initiative by IDSA The 10 x '20 Initiative is a global effort to foster development of 10 innovative antibiotics by 2020, sponsored by the Infectious Diseases Society of America (IDSA). Initiative by WHO Antimicrobial resistance is not a new problem but one that is becoming more dangerous; urgent and consolidated efforts are needed to avoid regressing to the pre-antibiotic era. WHO introduced a six-point policy package to combat the spread of antimicrobial resistance. 1. Commit to a comprehensive, financed national plan with accountability and civil Society engagement 2. Strengthen surveillance and laboratory capacity 3. Ensure uninterrupted access to essential medicines of assured quality 4. Regulate and promote rational use of medicines, including in animal husbandry, and ensure proper patient care 5. Enhance infection prevention and control 6. Foster innovations and research and development for new tools World Health Day 2011 Guideline for antimicrobials against AMR pathogens • No special guideline/guidance • Related guideline/guidance • U.S.FDA Guidance for Industry Antibacterial Therapies for Patients with Unmet Medical Need for the Treatment of Serious Bacterial Disease (Draft, 2013) • EMA Addendum to the Guideline on the Evaluation of Medical Products Indicated for Treatment of Bacterial Infections (2013) 15 April 2016 • How to enroll the patients? • Limited number of patients • How many clinical institutes should sponsor contract ? • How to demonstrate benefit-risk balance of the product? • Statistical verification → Impossible • Utilization of PK/PD, Modeling & Simulation ? • How to collect efficacy and safety data from development stage to post-marketing, continuously? Guideline for antimicrobials against AMR pathogens R&D to battle AMR pathogen 1. How to find potential seeds in laboratory? How to bring it from laboratory to clinical development? 2. What kind of collaboration is needed in regulators? • To develop clinical development guideline ? • Capacity Building ?
For academia? Healthcare Professionals? Regulators? Industries? 3. What is key elements to accelerate development of the antimicrobial agents? • Harmonized guideline for clinical development? • Governmental support? • Funding? R&D to battle AMR pathogen 1. How to find potential seeds in laboratory? How to bring it from laboratory to clinical development? 2. What kind of collaboration is needed in regulators? • To develop clinical development guideline ? • Capacity Building ?
For academia? Healthcare Professionals? Regulators? Industries? 3. What is key elements to accelerate development of the antimicrobial agents? • Harmonized guideline for clinical development? • Governmental support? • Funding? R&D to battle AMR pathogen 1. How to find potential seeds in laboratory? How to bring it from laboratory to clinical development? 2. What kind of collaboration is needed in regulators? • To develop clinical development guideline ? • Capacity Building ?
For academia? Healthcare Professionals? Regulators? Industries? 3. What is key elements to accelerate development of the antimicrobial agents? • Harmonized guideline for clinical development? • Governmental support? • Funding? R&D to battle AMR pathogen 1. How to find potential seeds in laboratory? How to bring it from laboratory to clinical development? 2. What kind of collaboration is needed in regulators? • To develop clinical development guideline ? • Capacity Building ?
For academia? Healthcare Professionals? Regulators? Industries? 3. What is key elements to accelerate development of the antimicrobial agents? • Harmonized guideline for clinical development? • Governmental support? • Funding?