Meeting Report
MEETING ON MULTISECTORAL ACTION ON ANTIMICROBIAL RESISTANCE IN CAMBODIA, LAO PEOPLE'S DEMOCRATIC REPUBLIC AND VIET NAM
18–20 January 2017 Hanoi, Viet Nam
Meeting on Multisectoral Action on Antimicrobial Resistance In Cambodia, Lao People's Democratic Republic and Viet Nam 18–20 January 2017 Hanoi, Viet Nam
RS/2017/GE/01(VNM)
English only
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
MEETING REPORT
MEETING ON MULTISECTORAL ACTION ON ANTIMICROBIAL RESISTANCE IN CAMBODIA, THE LAO PEOPLEʼS DEMOCRATIC REPUBLIC AND VIET NAM
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Hanoi, Viet Nam 18–20 January 2017
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines June 2017
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NOTE
The views expressed in this report are those of the participants of the Meeting on Multisectoral Action on Antimicrobial Resistance in Cambodia, the Lao Peopleʼs Democratic Republic and Viet Nam 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 Meeting on Multisectoral Action on Antimicrobial Resistance in Cambodia, the Lao Peopleʼs Democratic Republic and Viet Nam in Hanoi, Viet Nam from 18 to 20 January 2017.
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CONTENTS
Abbreviations ....................................................................................................................................... iv Summary................................................................................................................................................ v 1. Introduction ....................................................................................................................................... 6 1.1 Meeting organization ..................................................................................................................... 6 1.2 Meeting objectives ........................................................................................................................ 6 2. Proceedings ........................................................................................................................................ 6 2.1 Opening session............................................................................................................................. 6 2.2 Antimicrobial resistance in the Western Pacific Region ............................................................... 7 2.3 Multisectoral collaboration and action on AMR ........................................................................... 8 2.4 Awareness and advocacy on AMR................................................................................................ 8 2.5 Surveillance for action on antimicrobial consumption .................................................................. 8 2.6 Reducing the incidence of infection .............................................................................................. 9 2.7 Surveillance of AMR................................................................................................................... 10 2.8 Infection prevention and control and surveillance systems that can make a difference .............. 11 2.9 Sustaining action – systems to control AMR .............................................................................. 11 2.10 Global support to accelerate implementation of national action plans ...................................... 13 2.11 Country planning for the next steps for implementation of national action plans on AMR...... 14 2.12 Closing session .......................................................................................................................... 14 3. Conclusions and recommendations ............................................................................................... 14 3.1 Conclusions ................................................................................................................................. 14 3.2 Recommendations ....................................................................................................................... 15 3.2.1 Recommendations for Member States .................................................................................. 15 3.2.2 Recommendations for WHO ................................................................................................ 16 ANNEXES ........................................................................................................................................... 17 Annex 1. List of Participants ............................................................................................................. 17 Annex 2. Programme of Activities .................................................................................................... 21 Annex 3. Presentations ...................................................................................................................... 24
Keywords: Cambodia / Drug resistance, Microbial / Laos / Sentinel surveillance / Viet Nam
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ABBREVIATIONS AMC AMR AMS APSED CRE FAO GARP IPC MDR MRSA NCLE OIE PVS SDG SOP UHC UK US CDC WAAW WHO XDR antimicrobial consumption antimicrobial resistance antimicrobial stewardship Asia Pacific Strategy for Emerging Diseases carbapenem resistant Enterobacteriaceae Food and Agriculture Organization of the United Nations Global Antibiotic Resistance Partnership infection prevention and control multi-drug resistant methicillin resistant Staphylococcus aureus National Center for Laboratory and Epidemiology World Organisation for Animal Health performance of veterinary services Sustainable Development Goal standard operating procedures Universal Health Coverage United Kingdom United States Center for Disease Control World Antibiotic Awareness Week World Health Organization extremely drug resistant
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SUMMARY The rapid emergence and spread of antimicrobial resistance (AMR) threatens our ability to effectively treat and prevent infections, and ultimately, achieve the Sustainable Development Goals (SDGs). Concerted efforts to contain AMR require bold political commitment and strategies that span all relevant sectors, including human and animal health, aquaculture, agriculture and the environment. The Meeting on Multisectoral Action on Antimicrobial Resistance in Cambodia, the Lao Peopleʼs Democratic Republic and Viet Nam, held in Hanoi, Viet Nam from 18 to 20 January 2017 was organized by the World Health Organization (WHO) in close collaboration with the Food and Agriculture Organization of the United Nations (FAO) and World Organisation for Animal Health (OIE). Participants included technical experts from the health, agriculture, environment and trade sectors of the three countries. Cambodia, the Lao Peopleʼs Democratic Republic and Viet Nam are at different stages of progress in the development and implementation of multisectoral national action plans on AMR. Bringing together relevant sectors and development partners provided a unique opportunity to accelerate progress for concerted coordination and action to contain AMR across sectors and countries. The meeting discussed comprehensive policies and actions to implement national action plans on AMR appropriate to each country context and opportunities for strengthened regional collaboration. The importance of the multisectoral and multidisciplinary approach was highlighted, and AMR was framed as a development agenda in the context of universal health coverage (UHC) and achieving the SDGs. The meeting highlighted the WHO Global Action Plan on Antimicrobial Resistance and regional efforts to combat AMR. It also underscored the urgency of the AMR threat – both as a health threat to human and animal sectors and as a broader economic and development issue for countries that requires systems strengthening with a framework for action, which the meeting would address. The need for resource mobilization and capacity-building, as well as the need for further political engagement and the assurance that AMR is a priority for all ministries involved, was highlighted by all countries. The meeting also facilitated opportunities for exchange of lessons learnt and fostered collaboration among countries and across sectors by building regional capacities to combating AMR and coordinating activities through the WHO, FAO, OIE and other mechanisms, as appropriate. 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.
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1. INTRODUCTION
1.1 Meeting organization The Meeting on Multisectoral Action on Antimicrobial Resistance in Cambodia, the Lao Peopleʼs Democratic Republic and Viet Nam was held in Hanoi, Viet Nam from 18 to 20 January 2017, with participants from the ministries of health, agriculture, environment and trade from the three countries in the Greater Mekong Subregion. On day 1, welcome messages were delivered on behalf of WHO. Following the formal opening, the meeting was divided into 11 main sessions: 1) AMR in the Western Pacific Region 2) Multisectoral collaboration and actions on AMR 3) Awareness and advocacy on AMR 4) Surveillance for action on antimicrobial consumption (AMC) 5) Optimizing the use of antimicrobials 6) Reducing the incidence of infection 7) Surveillance of AMR 8) Infection prevention and control, and surveillance systems that make a difference 9) Sustaining action – systems support to control AMR 10) Global support to accelerate implementation of national action plans 11) Country planning for the next steps in implementation of national action plans on AMR. 1.2 Meeting objectives The objectives of the meeting were: 1) to identify gaps and challenges and share information and best practices on combating AMR across countries and on strengthening national multisectoral coordinating mechanisms for AMR; 2) to learn from relevant experiences of major disease programmes within the countries including HIV, tuberculosis and malaria; 3) to accelerate the development and implementation of multisectoral national action plans; and 4) to identify next steps for collective action to combat AMR in Cambodia, the Lao People's Democratic Republic and Viet Nam. 2. PROCEEDINGS 2.1 Opening session Dr Lokky Wai, WHO Representative to Viet Nam, provided opening remarks highlighting the importance of combating AMR in the Greater Mekong Subregion. Dr Vivian Lin, Director of the Division of Health Systems in the WHO Regional Office for the Western Pacific, delivered the 6
opening remarks on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific. She welcomed participants to the historic first meeting on AMR focusing specifically on Cambodia, the Lao People’s Democratic Republic and Viet Nam and underscored the urgency of the AMR threat both medically and economically. The threat, she said, requires close collaboration among the human and animal health sectors, the environment sector, and trade sectors. She highlighted the tremendous progress that the three countries had taken in combating AMR with national action plans in place or in final draft form. She also noted the high-level government commitments and pointed out that this momentum must continue as countries shift from policy into sustainable and coordination action on AMR. Following the introduction of participants, Dr Socorro Escalante, Team Leader for Health Systems at the WHO country office in Viet Nam, introduced the meeting objectives and agenda. Dr Sok Srun was appointed as chairperson and Dr Le Thi Hue as vice-chairperson. 2.2 Antimicrobial resistance in the Western Pacific Region Dr Lin presented the global picture of AMR, highlighting recent cases of untreatable gonorrhoea in Australia and Japan. She framed AMR in the context of UHC, One Health and the ultimate achievement of the SDGs. Moving from policy to action, particularly for health systems strengthening to combat AMR, requires a framework for action that simultaneously strengthens efforts to prevent the further emergence and spread of resistant infections along with the curbing the inappropriate use of antibiotics. Her presentation provided an overview for the three-day meeting. Dr Katinka de Balogh spoke about the threat of AMR to food security, in particular to achieving SDG 2, which calls for the elimination of hunger, from the perspective of FAO. She explained the historical trajectory of agriculture resulting in faster and more cost-effective methods in bringing products from farm to fork, which has led to an increase in antibiotics both for the treatment of livestock and growth promotion. In order to combat AMR and its further emergence and spread in the animal and human health sectors, she emphasized the need for countries to balance adequate crop and animal production for food security with decreasing inappropriate and overuse of antibiotics. In conclusion, Dr de Balogh said there was a need to find joint solutions across sectors and countries through a One Health approach to combating AMR. Dr Pennapa Matayompong provided an overview of the challenges of AMR in Asian livestock, as well as an overview of OIEʼs global programme for quality of veterinary services, including the OIE tool for the evaluation of the performance of veterinary services for which none of the three Mekong countries had reached beyond Level 3 out of five levels. She provided recommendations in moving forward to strengthen the animal health sector in combating AMR. The recommendations include: 1) the need for relevant legislation to prevent the inappropriate use of veterinary antimicrobials; 2) strengthening laboratory capacity for resistant pathogens and antibiotic residues in animal products; and 3) strengthening effective communication and collaboration across the relevant sectors and stakeholders at the national, regional and global levels. Professor Guy Thwaites shared a comparative picture of AMR in Cambodia, the Lao People’s Democratic Republic and Viet Nam. The overview of the literature presented on AMR across SouthEast Asia showed high levels of multidrug-resistant (MDR) gram-negative bacteria. However, he noted that there were large gaps in AMR data, in particular from Cambodia and the Lao People’s Democratic Republic leading to difficulties in comparing the situation of AMR across Cambodia, the Lao People’s Democratic Republic and Viet Nam in particular. Professor Thwaites showed that there were high levels of MDR gram-negative and methicillin-resistant Staphylococcus aureus (MRSA) infections in hospital and community settings in Viet Nam; however, resistance to carbapenem was 7
still rare in the community. Data from Cambodia suggest that MRSA is equally on the rise, and the limited data collected in the Lao People’s Democratic Republic indicated lower levels of resistance across all bacteria. 2.3 Multisectoral collaboration and action on AMR Dr Escalante gave an introductory presentation on the lifecycle of antibiotics and the need for multisectoral collaboration and action on AMR. She mentioned the role that the environment plays as a common denominator and breeding ground for AMR and provided examples of complex issues requiring multisectoral coordination, such as the need to reduce antibiotic residues in the water stemming from health-care facilities and pharmaceutical industry run-off to name a few. Dr Escalante also linked containment of AMR directly to achieving SDGs 1, 2, 3, 6, 8, 12 and 17. The introductory presentation was followed by country presentations on the governance of AMR, with a focus on national mechanisms, challenges, and next steps for development and implementation of national action plans on AMR. All three countries are at different stages in the finalization and implementation of their national action plans, with various entry points for political engagement identified. A common challenge across the countries was the need to mobilize additional financial and human resources. Following the country presentations a panel discussion was held on how to strengthen collaboration across sectors. Dr Lin moderated the panel discussion, which included the need to balance practical and concrete small steps in each sector with the broader cross-sectoral AMR agenda to stimulate further engagement and resource mobilization. In addition, the need to engage additional sectors such as ministries of education was identified as critical for a comprehensive approach to tackling AMR in countries – an approach that balances appropriate access to quality-assured antimicrobials with the decrease in inappropriate use. 2.4 Awareness and advocacy on AMR Dr Sarah Paulin, responsible officer for the meeting, spoke on the importance of AMR awareness raising and advocacy and emphasized World Antibiotic Awareness Week (WAAW), noting some country highlights from the 2015 and 2016 campaigns. She explained that the aim of WAAW was to move the issue of AMR from the scientific communities to policy-makers, the general public and health professionals. Dr Paulin also emphasized that awareness-raising and advocacy activities must go beyond WAAW, including but not limited to continuing medical education, the inclusion of AMR in school curriculum, strengthening of AMR postgraduate education, and the celebration and overall building of an environment and infrastructure that drives behaviour change. Following the introductory presentation, countries provided brief presentations on national awareness and advocacy campaigns conducted and the next steps to drive behaviour change required for rational use of antimicrobials and combating AMR. Following the presentation, Dr Paulin moderated a panel discussion on how to achieve behaviour change on AMR. The need for a stratified approach involving various target groups was considered critical, requiring simple and clear messaging and champions to drive the change. 2.5 Surveillance for action on antimicrobial consumption Dr Paulin provided an introductory presentation featuring an example of a simple human and animal health framework for action to control and reduce AMR that requires high-level political engagement and multisectoral collaboration, combined with a two-pronged approach to reducing both infections and the inappropriate use of antimicrobials. Monitoring of antimicrobial consumption was considered fundamental to reducing the inappropriate use of antimicrobials. 8
Dr Ketevan Kandelaki provided a presentation on AMC monitoring in the human health-care setting. She emphasized that the misuse of antimicrobials is accelerating the development of AMR; therefore, regular monitoring of AMC was critical to identify the actual amount of antimicrobials being consumed in countries. The WHO methodology on AMC was introduced, which had been rolled out to the three countries in a subregional workshop in October 2016. Since the workshop, Viet Nam has initiated action to begin monitoring consumption in the human health sector, and further capacitybuilding will take place for Cambodia and the Lao People’s Democratic Republic in order to initiate action in 2017. Dr Yooni Oh shared information on the antimicrobial usage data collected in animals as part of the OIE Sixth Strategic Plan (2016–2020). OIE also developed a procedure and standards for ensuring data quality in the annual collection of data on antimicrobial usage in food-producing animals. The first phase of data collection was initiated at the end of 2015 with 130 Member States providing quantitative data. The OIE report, which is available online, primarily captures wholesaler and importer data for antimicrobial usage in animals. Dr Susan Luu presented on the opportunities and challenges of antimicrobial stewardship (AMS) programmes in hospitals. She described AMS as coordinated interventions designed to measure and improve the appropriate use of antimicrobials by promoting selection of the optimal antimicrobial drug regimen, dose, duration and route of administration for patients. AMS strategies may include restriction criteria for essential medicines lists, national treatment guidelines, reporting of antimicrobial susceptibility testing, audit and feedback, and post-prescription reviews. In implementing sustainable AMS programmes in hospitals; Dr Luu highlighted some of the key challenges for low- and middle-income countries that include ensuring adequate financial resources, training health-care professionals in AMS (especially clinical pharmacists), implementation models, and overall behaviour change for health-care professionals and patients seeking treatment. The presentations were followed by group work on optimizing the use of antimicrobials. Two groups were formed with Group 1 focusing on building capacity for AMC in the human health sector and Group 2 focused on building capacity in the animal husbandry sector. Entry points were identified for collection of AMC data. The groups were organized along the following lines: Human health sector: Cambodia: hospital data Lao People’s Democratic Republic: procurement data Viet Nam: insurance and customs data
Animal husbandry sector: Cambodia: import data Lao People’s Democratic Republic: import data Viet Nam: import and manufacturer data.
2.6 Reducing the incidence of infection Dr Masaya Kato gave a presentation on addressing AMR as a global health security threat and the important role of infection prevention and control (IPC) combating the threat. He highlighted the importance of IPC in the national response to AMR as indicated in Strategic Objective 3 of the Global Action Plan on Antimicrobial Resistance: "reduce incidence of infection through effective sanitation, hygiene and infection prevention measures". In addition, the Asia Pacific Strategy for Emerging 9
Diseases and Public Health Emergencies endorsed by the WHO Regional Committee for the Western Pacific in 2016 identified strengthening of IPC as a key focus area and integral to functioning healthcare systems. Dr Kato shared a recent response to carbapenem-resistant Enterobacteriaceae (CRE) events at the national hospital in Hanoi from 2015 to 2016. Through the quick development of a CRE response plan, which focused on strengthening IPC together with efforts to optimize the use of antimicrobials, the hospital was able show a decrease in reported CRE cases. Dr Kato mentioned that main priorities for the response were hospital leadership and governance, as well as strengthening hand-hygiene compliance by health-care professionals. Dr Kayoko Hayakawa spoke on the opportunities and challenges for IPC in the Greater Mekong Subregion. She discussed various approaches to strengthening IPC in hospitals, including ensuring hospital leadership and governance, active surveillance of hospital-acquired infections and antimicrobial susceptibility testing, hand hygiene, strict IPC compliance for high-risk patients, addressing overcrowding in particular at national hospitals, and enhancing capacities to investigate hospital-based outbreaks. She concluded by saying that in order to have functional AMS and IPC programmes in hospitals, the two programmes must be linked. Dr Long Ngoc Khue shared lessons learnt from disease programmes in the prevention and control of AMR, in particular to multidrug-resistant (MDR) tuberculosis (TB) in Viet Nam. Dr Khue noted that experiences from the TB programme in Viet Nam – based on the magnitude of MDR and extensively drug-resistant TB problem there – showed that it is a complex issue and that multiple components are equally important. These components include human resources, adequate financing, laboratory capacity with quality-assurance systems, IPC, quality-control systems, pharmacovigilance and drug supply systems to ensure access to quality-assured anti-TB treatment. He concluded by saying it was crucial to have in place well-functioning treatment services from tertiary hospitals to community health-care facilities. 2.7 Surveillance of AMR Dr Alexandre Rabello Tenorio da Costa provided an introductory presentation on the surveillance of AMR and laboratory capacity, with particular regard to the development of an AMR national surveillance system. AMR surveillance has been a priority for WHO as identified in the WHO Global Strategy for Containment of Antimicrobial Resistance (2001), the WHO Policy Package to Combat Antimicrobial Resistance (2011) and the more recent Action Agenda for Antimicrobial Resistance in the Western Pacific Region and the WHO Global Action Plan on Antimicrobial Resistance. He concluded by noting that surveillance systems are essential to local, national and international efforts on AMR. Countries are beginning enrollment into the Global Antimicrobial Resistance Surveillance System (GLASS), which provides laboratory capacity-building to develop a national surveillance system with reporting of priority pathogens for national, regional and global comparison. Two country presentations on AMR surveillance followed the introductory presentation. Dr Sok presented on AMR surveillance in Cambodia. He described the setup of the AMR national surveillance programme that was developed by the AMR working group. The surveillance system has a designated national reference laboratory at the National Public Health Laboratory and collects and reports on surveillance of routine blood culture isolates of four priority pathogens based on recommendations from GLASS, which Cambodia has enrolled in. Dr Sok noted that currently 17 laboratories perform antibiotic susceptibility testing in the surveillance system and participate in the external quality assessment programme of the Pacific Paramedical Training Centre in Wellington, New Zealand. He also discussed some of the major gaps and challenges in surveillance in Cambodia, which include lack of human resource capacity, lack of collection of patient epidemiology data to 10
support the laboratory data, and a weakness in data management, analysis and dissemination to inform interventions at the local and national levels. Dr Phengta Vongphrachanh delivered a presentation on the capacity of the Lao People’s Democratic Republic for AMR surveillance. Four centres were identified with capacity for antimicrobial susceptibility testing: the National Center for Laboratory and Epidemiology (NCLE), Mahosot Hospital, the National Tuberculosis Center, and the Centre for Malaria Parasitology and Entomology. Data were presented on diarrhoea surveillance in eight sentinel sites as part of NCLEʼs programme with Salmonella species, accounting for the highest amount from bacterial causative agents. Dr Vongphrachanh also identified gaps and challenges for AMR surveillance in the Lao People’s Democratic Republic which include not having an AMR national surveillance plan, project-based testing as opposed to routine antimicrobial susceptibility testing, limited coordination and information sharing among laboratories, and limited human and financial resources. She concluded by highlighting the importance of awareness and coordination among stakeholders on AMR in the Lao People’s Democratic Republic. 2.8 Infection prevention and control and surveillance systems that can make a difference Dr Kayoko Hayakawa delivered a presentation on the fundamentals of setting up IPC programmes at the facility level. She said a multimodal strategy is important when setting up IPC programmes that are integrated and aim to improve practices and reduce health-care-associated infections and the further emergence and spread of AMR. This multimodal strategy or bundle should be developed and implemented by a multidisciplinary team within hospitals that incorporate the following key components: system change, education and training, monitoring and feedback reminders, and culture and behaviour change to strengthen patient safety. She concluded by noting that healthy workplace competition on hand-hygiene compliance in health-care facilities can foster change. Dr Do Thi Thuy Nga presented on behalf of the Oxford University Clinical Research Unit in Viet Nam (OUCRU). She described the history of developing the Viet Nam surveillance system that stems back to 1989, with funding from the Swedish International Development Agency to support an antibiotic susceptibility-testing project. This project led to various publications as well as the training of bacteriology and laboratory technicians in all provincial hospitals. A situational analysis was conducted in 2009 together with the Global Antibiotic Resistance Partnership (GARP), which informed the development of Viet Namʼs national action plan in 2013- the first such plan in the Western Pacific Region. The plan identified strengthening surveillance of antibiotic use and resistance as one of the priorities. In 2015, a grant from the Fleming Fund of the United Kingdom of Great Britain and Northern Ireland supported the development of a national reference laboratory for Viet Namʼs national surveillance system, in collaboration with OUCRU and the national hospital for tropical diseases. Laboratory capacity-building for the national surveillance system remains a priority for Viet Nam. Following the presentations, the participants were offered two site visits: the Bac Mai Hospital to learn about its antimicrobial stewardship programme and an animal feed mill to observe operations. The hospital visit was successful; however, due to traffic the second group could not reach the feed mill and instead stopped at roadside street-food stalls as an impromptu site visit on food safety and AMR. 2.9 Sustaining action – systems to control AMR Dr Lin framed AMR as a development issue in the context of UHC, One Health and the SDGs. UHC plays a vital role in protection from the financial burdens that can arise from AMR. In the growing 11
global economy, all countries are connected through the movement of people and products. AMR threatens food security for rapidly increasing populations and growing economies, and thus the achievement of the SDGs. She emphasized that the control of AMR requires coordinated strategies involving multiple sectors: human and animal health, agriculture, food production and food safety, environmental protection, and trade. She called for collective action on AMR at the national, regional and global levels. All countries play a vital role in these efforts. She also pointed out the importance of awareness raising, behaviour change, changing the views of consumers and the community, and the need of higher-level political commitments. Following the introductory presentation, a panel discussion, moderated by Dr Lin, identified the systems, structures and legal frameworks that are essential to sustaining multisectoral action against AMR. The following points were identified as crucial: National priority: linking AMR to the national development agenda and framing it in the context of UHC, SDGs and other national priorities across the relevant sectors to ensure national recognition and support across the ministries of health, agriculture, environment and others. Moving from policy to action: o having a clear and feasibly operational plan to implement the national action plan with clear goals and outcomes, prioritized actions, and an identified budget, timeline and responsible implementer; balancing practical and concrete small steps/actions with the broader multisectoral AMR agenda to stimulate engagement and ownership; demonstrating small successes in each sector to build upon in a stepwise manner; and seeking technical and financial support from international organizations and development partners.
o o o
Additional sectors: bringing on board additional sectors including the ministry of education through understanding their motivation and how AMR links to their sector and national agenda. Delineating roles and responsibilities: identifying and clarifying roles and responsibilities of each sector with the support of international organizations. Financing: ensuring adequate finance structures to support multisectoral coordination that goes hand in hand with ensuring AMR as a national priority linked to existing national health and development agendas. Regulation: recognizing that regulations are required and that they are aligned with financial incentives. Cross-border issues: understanding the differences and commonalities through regular information sharing across sectors and countries to ensure coordinated action on AMR. Evidence for policy decisions and informed interventions: strengthening the evidence base through collection, analysis and dissemination of AMR surveillance and AMC monitoring data to convince policy-makers that AMR is a national priority and to inform evidence-based interventions.
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Behaviour change: using the power of financing and incentives to educate and persuade the general public to change their consumer habits in relation to disease prevention and use of antimicrobials.
2.10 Global support to accelerate implementation of national action plans Dr Lan Yun provided a presentation on the activities of the United States Centers for Disease Control and Prevention (USCDC) for building national capacity for AMR surveillance and infection control in Viet Nam. Through the support of technical and financial support from USCDC, capacity-building for AMR surveillance has been undertaken that included the hiring of five full-time laboratory staff, development of microbiology and infection-control guidelines and standard operating procedures, AMR national surveillance policy documents, training on the laboratory information management system WHONET, external quality assurance and other measures. Viet Nam now has an AMR surveillance system in place that gathers AMR surveillance data from 16 hospitals in the Viet Nam through data submission via WHONET to the Ministry of Health on a quarterly basis. The system has an alert function for detecting resistant pathogens, which leads to confirmatory testing and analyses at the reference laboratory. This was one example of the USCDCʼs support to establishing and/or strengthening an AMR national surveillance system, which is undertaken in close collaboration with WHO and OUCRU, among others. Mr Anthony Huszar shared the Fleming Fundʼs plans for country and regional grants and the Fleming fellowship scheme to support multisectoral action on AMR. He noted that approximately £ 265 million would be available to fund AMR activities over a five-year period across four regions, including the WHO Western Pacific Region. The Fleming Fund is currently undergoing an eightmonth inception period that will be concluded in June 2017, which includes in-country assessments, meetings with stakeholders, developing a funding stream and allocation models, identifying 20–30 priority countries to support, developing calls for proposals, and identifying countries for early investment and piloting. The core principles for grants will include the existence of an AMR national action plan with a One Health approach, country ownership, alignment of the approach with existing country priorities and the sustainability of actions. Areas of potential investment were identified as the following: strengthening AMR coordinating committees through the fellowship programme building laboratory capacity for AMR surveillance collating and analysing data on AMC and antimicrobial use promoting the rational use of antimicrobials shaping a sustainable system for AMR.
Mr Huszar mentioned that the first call for country grants most likely will come in June 2017, with US$ 5 million to US$ 15 million allocated per country over a five-year period of initial support. Dr Hellen Gellband presented a global overview of GARP. She described GARP as a network of interdisciplinary national working groups catalysing the development and implementation of AMR national action plans primarily supported by the Bill & Melinda Gates Foundation. The aim of GARP is to develop the evidence base for policy action on antibiotic resistance through national situation analyses. In close consultation with governments, GARP supports the development of national action plans and supports translating action plans into implementation plans with prioritized activities and costs over three to five years. Viet Nam was one of the Phase 1 countries in 2008–2009. The Lao 13
People’s Democratic Republic is one of the countries in Phase 3 from 2016–2018, and work has been initiated to complement the draft national action plan already developed in the Lao People’s Democratic Republic by the AMR committee. GARP's approach includes working with national technical experts across both public and private sectors and urban and rural areas. In Phase 3, GARP will request government support and coordinate closely with FAO, OIE and WHO country offices, regional offices and headquarters. It will also focus on creating national plans with costed operational plans for implementation and support countries in long-term sustainability of actions and monitoring of implementation of the national action plans. 2.11 Country planning for the next steps for implementation of national action plans on AMR In group work consisting of country groups, five-year country plans were prepared on next steps in the implementation of AMR national action plans across the following areas: strengthening governance; improving awareness and understanding of AMR; AMR surveillance and monitoring of AMC; sanitation, hygiene and IPC; and optimizing the use of antimicrobials in human and animal health. The media was invited to the plenary during which countries reported back on their workplans. 2.12 Closing session The meeting summary and recommendations were reviewed and adopted by the meeting participants. Dr Paulin and Dr Escalante provided closing remarks. They applauded the participants for the ongoing work on AMR and future plans to turn policy into action. It was acknowledged that there is still a substantial amount of work to be done, but observations made throughout the meeting showed a commitment across the four sectors in the three countries on collective action to combat AMR. It was also noted that the meeting provided a unique opportunity to identify common challenges and solutions on combating AMR and moving forward to combat AMR collectively in the Greater Mekong Subregion countries in the Western Pacific Region. 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions The meeting discussions focused on moving forward with comprehensive policies and actions to implement AMR national action plans appropriate to each country context and opportunities for strengthened regional collaboration. The importance of the multisectoral and multidisciplinary approach was highlighted, and AMR was framed as a development agenda in the context of UHC and achieving the SDGs. The meeting highlighted the WHO Global Action Plan on Antimicrobial Resistance and regional efforts to combat AMR and also underscored the urgency of the AMR threat –both as a health threat to the human and animal sectors, but also as a broader economic and development issue for countries that requires systems strengthening with a framework for action that the meeting addressed. The need for resource mobilization and capacity-building, as well as the need for further political engagement and ensuring that AMR is a priority for all ministries involved, was highlighted by all countries. The meeting also considered how to prevent the crossover of antibiotic use between the animal and human health sectors, the importance of creating an environment for the rational use of antimicrobials, and ended on the difficult subject of how to better engage the private and pharmaceutical sectors. The importance of identifying the required behaviour change, identifying champions, the need for stratified approaches to targeting various groups, and the importance of simple messaging and terminology to encourage the responsible use of antibiotics were also discussed. 14
In order to ensure multisectoral collaboration and actions to contain AMR, it is crucial to develop national surveillance systems for action to inform evidence-based interventions and ultimately effective governance mechanisms. The meeting discussed the need for a robust framework to monitor and evaluate implementation of national action plans. Discussions were also held on the importance of monitoring of AMC in the animal and human health sectors, as well as the importance of AMS programmes and IPC programmes in hospitals. Other key issues included identifying systems, structures and legal frameworks that are essential to sustain multisectoral actions against AMR, as well as legislation and the enforcement of relevant legislation to tackle AMR. The meeting provided a unique opportunity to consider opportunities for multisectoral collaboration across Cambodia, the Lao People’s Democratic Republic and Viet Nam, as well as the Greater Mekong Subregion. Collective action on AMR can serve as an appropriate model of an integrated and indivisible approach to achieving the SDGs. 3.2 Recommendations 3.2.1 Recommendations for Member States 1) 2) 3) 4) 5) Member States are encouraged to share their five-year plans, prepared during the meeting, with their national AMR committee in their respective countries and elevate it to the ministerʼs level. Member States are urged to link the AMR agenda to national development agendas, for example, UHC, One Health and the SDGs, to ensure national recognition and support. Member States with support from the tripartite partners (FAO, OIE and WHO) should ensure adequately financed structures to support multisectoral coordination. Member States are encouraged to continue to share information across sectors and countries on the challenges and successes in terms of multisectoral coordination and action on AMR. Member States are recommended to clarify and identify roles and responsibilities of all stakeholders, including international organizations and other sectors, in supporting the implementation of AMR national action plans. Member States are urged to strengthen evidence through surveillance of AMR and AMC to influence policy-making. Member States are recommended to collaborate with other sectors, including the ministry of education, to combat AMR. Member States are urged to use existing programmes and strategies, such as hand hygiene and rational drug use programmes, to raise awareness and strengthen basic hygiene and sanitation. Member States are recommended to institutionalize IPC practices through a multimodal approach. Member States are urged to raise awareness by adapting their messaging and interventions to target groups, such as human and animal health professionals, policy-makers and the general public. Member States are recommended to raise awareness on the threat of AMR outcomes and to suggest ways to “make the healthier choices the easier choices” in order to change behaviour across target groups, particularly policy-makers. Member States are recommended to enforce legislation on prescription-only use of antibiotics in both the human and animal health sectors. Member States are urged to continue phasing out the use of antimicrobials as growth promoters in animals.
6) 7) 8) 9) 10)
11)
12) 13)
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3.2.2 Recommendations for WHO 1) WHO is encouraged to continue to support Cambodia, the Lao People’s Democratic Republic and Viet Nam in finalizing and implementing their national action plans, as well as supporting resource mobilization and capacity-building. WHO, together with FAO and OIE, should monitor progress made in implementing the national action plans and the five-year commitments made during the meeting by holding annual AMR meetings with the three countries. WHO is encouraged to better utilize technological innovations and the media to raise awareness and continue advocacy for behaviour change using a stratified approach for key target groups. WHO, together with FAO and OIE, should promote annual World Antibiotic Awareness Week (WAAW) activities in all countries to deliver messages that address the challenges shared by the human, animal and agricultural sectors. WHO is encouraged to continue to support Member States in the development and implementation of their AMR multisectoral national action plans. WHO, in collaboration with FAO and OIE, should foster regional collaboration and information sharing across sectors and countries on developing and implementing AMR national action plans.
2)
3) 4)
5) 6)
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ANNEXES
Annex 1. List of Participants
1. PARTICIPANTS
Cambodia
SOK Srun, Director, Department of Hospital Services, Ministry of Health, No 80 Samdech Penn Nouth, Phnom Penh, Tel: +855 12 912122, E-mail: soksrun@online.com.kh Dr LY Sovann, Director, Department of Communicable Diseases and Control, Ministry of Health, No 80 Samdech Penn Nouth, Phnom Penh,Tel: +855 12 825424, E-mail: sovann_ly@online.com.kh Mr SIN Sideth, Director of Laboratory, Cambodia Import Export Inspection and Fraud Repression, Directorate-General, Ministry of Commerce, Kdey Takoy Village, Phnom Penh, Tel: +855 12 278 789, E-mail: sinsidethmoc@gmail.com Mr CHHIN Nith, Chief, Office of Biosafety, Department of Biodiversity, Ministry of Environment, #503, Morodok Techo Building, Phnom Penh, Tel: +855 77272200, E-mail: chhinnith@gmail.com Mr CHEA Sokhom, Animal Disease Control and Antimicrobial Coordinator, Department of Animal Health and Production (GDAHP), Ministry of Agriculture, Forestry and Fisheries, Tel: +855 12 829 425, Email: bbc.sokhom@gmail.com Mr TEP Bengthay, Animal Disease Control and Antimicrobial Coordinator, General Directorate of Animal Health and Production (GDAHP), Ministry of Agriculture, Forestry and Fisheries, Tel: +855 12 9148 48, E-mail: bengthay@gmail.com
Lao People’s Democratic Republic
Mr Sithong PHIPHAKHAVONG, Deputy Director-General Department of Livestock and Fisheries, Ministry of Agriculture and Forestry, Souphanouvong Road, Vientiane, Tel: +856 21 215242 E-mail: sithongp@yahoo.com Mr Sithong PHIPHAKHAVONG, Deputy Director-General, Department of Livestock and Fisheries, Ministry of Agriculture and Forestry, Souphanouvong Road, Vientiane Tel: +856 21 215242, E-mail: sithongp@yahoo.com Dr Boualam KHAMLOME, Deputy Chief, Prevention Division, Department of Communicable Diseases Control, Ministry of Health Sisattanack District, Vientiane, Tel: +856 21 264 324, Email: drboualamkhamlome@gmail.com 17
Dr Phengta VONGPHRACHANH, Director, National Center for Laboratory and Epidemiology, Ministry of Health, Vientiane, Tel: +856 21 312351, E-mail: v.phengta@gmail.com Mr Khamsonvanh PHUTDAVONG, Deputy Director General, Department of Planning and Cooperation, Ministry of Industry and Commerce, Chantaboury District, Vientiane, Tel: 020 999 643 44, E-mail: kphutdavong@gmail.com Dr Sommana RATTANA, Deputy Chief, Local Hospital Division, Department of Health Care, Ministry of Health, Sysactanak District, Vientiane, Tel: +856 20 556 14968, E-mail: sommana_68@yahoo.com Mrs Kongmany NAMMAVONGMIXAY, Deputy Chief, Information, Education and Communication Division, Food and Drug Department, Ministry of Health, Vientiane, Tel: +856 21 214013,020 55485404, Email :kongfdd@yahoo.com
Viet Nam
Mr PHAM Minh Tuan, Deputy Head, Goods Quality Control Department Market Surveillance Agency, Ministry of Industry and Trade, 91 Dinh Tien Hoang, Hanoi, Tel: +84 4 382 55868, E-mail: phamminhtuan8888@gmail.com Dr LE Thi Hue, Deputy Head, Veterinary Drug Management Division, Department of Animal Health, Ministry of Argiculture and Rural Development, Tel: +84 438 697150, E-mail: lehue1973@gmail.com Ms NINH Thi Ha, Official, Pollution Control Department, Vietnam Environment Administration, Ministry of Natural Resources and Environment, Tel:+844 379 56868 (ext 3219), E-mail: Haninh2011@gmail.com Ms NGO Thi Bich Ha, Department of Medical Service Administration Ministry of Health, 138 ADa Binh District, Giang Vo Street, Hanoi Tel: +844 627 32445, E-mail : bichhamoh@gmail.com
Mr LE Quang Huy, Staff, Veterinary Drug Management Division Department of Animal Health, Ministry of Agriculture and Rural Development, Hanoi, Tel: +84 0913355340, E-mail: quanghuyda@gmail.com
2. TEMPORARY ADVISERS Dr Kayoko HAYAKAWA, Infectious Disease Physician, National Center for Global Health and Medicine Hospital,Tokyo, Japan, Tel: +81 3 3202 7181,E-mail: kayokohayakawa@gmail.com
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Ms Susan Binh LUU, Director of Clinical Services, National Centre for Antimicrobial Stewardship Doherty Institute, 792 Elizabeth St, Melbourne, Australia, Tel: +61 3 93429422, E-mail: susan.luu@mh.org.au Dr Luong NGOC KHUE, General Director, Department of Medical, Service Administration Ministry of Health, Hanoi, Tel: +84 4 919121818, E-mail: khuebyt@yahoo.com Professor Guy THWAITES, Director, Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam, Tel: +84 8 39237954, E-mail: gthwaites@oucru.org 3. OBSERVERS Dr Hellen GELBAND, Associate Director, Center for Disease Dynamics, Economics and Policy (CDDEP), 1400 Street NW, Washington, D.C. 20005, United States of America, Tel: +1 202 328 5170, E-mail: gelband@cddep.org Mr Pawin PADUNGTOD, Senior Technical Coordinator, Emergency Centre for Transboundary, Animal Diseases (ECTAD) FAO Viet Nam Office, 304 Kim Ma Road, Hanoi, Tel: +84 4 38500393, E-mail: Pawin.Padungtod@fao.org Dr Anthony HUSZAR, Regional Coordinator, The Fleming Fund, Mott MacDonald 10 Fleet Place, London EC4M 7RB, United Kingdom, Tel: +44 20 7651 0300, E-mail: Anthony.Huszar@mottmac.com Dr DO Thi Thuy Nga, Coordinator, Oxford University Clinical Research Unit 78 Giang Phong Dong Da, Hanoi, Tel: +844 35764320, E-mail: ngadtt@oucru.org Ms NGIEM NGUYEN MINH TRANG, Coordinator, Oxford University Clinical Research Unit 78 Giang Phon Dong Da, Tel: +844 35764320, E-mail: trangnnm@oucru.org Dr Anthony MOUNTS, Acting Country Director, United States Center for Disease Control Viet Nam, 5th Floor Tungshing Building, 2 Ngo Quyen, Hanoi, Viet Nam, Tel: +844 3935 29229, E-mail: apm8@cdc.gov
4. SECRETARIAT 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 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 Ketevan KANDELAKI, 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 02 5289848, Email: kandelakik@who.int Ms Lkhagvadorj VANCHINSUREN, Technical Officer, World Health Organization Cambodia, Khan Chamkamorn, Phnom Penh, Cambodia, Tel: +855 23 216610, E-mail: lkhagvadorjv@who.int Dr Ayesha DE LORENZO, Technical Officer, World Health Organization Lao People’s Democratic Republic, 125 Saphanthong Road, Sisattanak District, Vientiane, Lao People’s Democratic Republic, Tel: ++856 21 35 3902, E-mail: delorenzoa@who.int 19
Dr Socorro ESCALANTE, Team Leader, Health Systems, World Health OrganizationViet Nam, 304 Kim Ma St, Hanoi, Viet Nam, Tel: +84 4 385 00308, E-mail: escalantes@who.int Dr Masaya KATO, Team Leader, Communicable Diseases, World Health Organization Viet Nam, 304 Kim Ma St, Hanoi, Viet Nam, Tel: +84 4 394 44734, E-mail: katom@who.int Dr Katinka DE BALOGH, Senior Animal Health and Production Officer, FAO Regional Office for Asia and the Pacific, 39 Phra Atit Road, Phranakon, Bangkok 10200, Thailand, Telephone: 66 2697 4323, Email: katinka.debalogh@fao.org 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 Dr Pennapa MATAYOMPONG, OIE SRR SEA Programme Coordinator, OIE Sub-Regional Representation for South-East Asia, Bangkok, Thailand, Tel: 66 2653 4864, E-mail: p.matayompong@oie.int
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Annex 2. Programme of Activities Day 1. 18 January 2017 8:30 – 9:00 Registration 9:00 – 9:30 Opening session – Plenary Welcome messages Dr Lokky Wai, WHO Representative Viet Nam Dr Vivian Lin, on behalf of WHO Regional Director for the Western Pacific Introductions Objectives of the meeting - Dr Socorro Escalante, WHO Election of chairpersons (2) Group Photo 9:30- 10:30 Session 1-Plenary: Antimicrobial resistance in the Western Pacific Region Antimicrobial resistance: the global picture (10 min) - Dr Vivian Lin, WHO Antimicrobial resistance: threat to food security (10 min) – Dr Katinka De Balogh, FAO Challenges of antimicrobial resistance in Asian livestock (10 min) - Dr Pennapa Matayompong, OIE Comparative picture of antimicrobial resistance in Cambodia, Lao PDR and Viet Nam (10 min) – Prof Guy Thwaites, OUCRU Coffee break Session 2-Plenary: Multisectoral collaboration and action on antimicrobial resistance Moderator and introductory presentation (5 min): Dr Socorro Escalante, WHO Reflections on multisectoral collaboration and action on antimicrobial resistance: national mechanisms, challenges and next steps for implementation of national action plans (10 min country presentations) o Cambodia AMR committee member o Lao PDR AMR committee member o Viet Nam AMR committee member Plenary discussion Lunch Session 3-Debate and dialogue panel discussion: Multisectoral collaboration and action on antimicrobial resistance Moderator: Dr Vivian Lin, WHO Panel topic: How can we strengthen collaboration across sectors o Shared challenges and best practices for multisectoral collaboration o Role of professional societies and organizations o Role of the pharmaceutical sector, private sector etc. Panel members: Dr Socorro Escalante (WHO), Dr Pennapa Matayompong (OIE), Prof Guy Thwaites (OUCRU), US CDC Coffee break Session 4-Plenary: Awareness and advocacy on antimicrobial resistance World Antibiotic Awareness Week (10 min)– Dr Sarah Paulin, WHO Reflections on awareness and advocacy campaigns conducted and next steps (10 min country presentations) o Cambodia AMR committee member o Lao PDR AMR committee member o Viet Nam AMR committee member Session 4-Panel discussion Moderator: Dr Sarah Paulin, WHO Panel topic: How can we achieve behavior change on AMR? o Role of other sectors o Role of professional organizations Panel members: Dr Susan Luu (Australia), Dr Katinka De Balogh (FAO), Dr Vivian Lin 21
10:30-11:30 11:30-12:30
12:30-13:30 13:30-14:30
14:30-15:00 15:00-16:30
(WHO), Dr Kayoko Hayakawa (Japan) 17:00-18:00 Reception and end of day 1
Day 2. 19 January 2017 8:30- 8:40 Recap of Day 1 - Dr Ayesha de Lorenzo, WHO 8:40-9:30 Session 5 – Plenary: Surveillance for action on antimicrobial consumption Human and animal health framework for action on antimicrobial resistance (5 min) – Tripartite (FAO, OIE, WHO) AMC monitoring in human health-care (10 min) – Dr Ketevan Kandelaki, WHO Antimicrobial Usage (AMU) data collection in animals (10 min) – Dr Yooni Oh, OIE Antimicrobial stewardship programmes in hospitals: opportunities and challenges (10 min) – Dr Susan Luu, Australia 9:30-10:30 Session 6 –Group work: Optimize use of antimicrobials Group 1: Building capacity for AMC monitoring in human health Group 2: Building capacity for AMC monitoring in animal husbandry Plenary – reporting back from group work discussions 10:30-10:50 Coffee break 11:50-11:30 Session 7 - Plenary: Reducing the incidence of infection AMR as a health security threat: Prevention of health-care associated infections, a priority of ASPED (10 min) – Dr Masaya Kato, WHO Infection prevention and control in the Greater Mekong Subregion: opportunities and challenges (10 min) – Dr Kayoko Hayakawa, Japan Lessons learnt from disease programmes for prevention and control of antimicrobial resistance (10 min) – Dr Long Ngoc Khue, Viet Nam 11:30-12:30 Session 8 – Plenary: Surveillance of antimicrobial resistance Introductory presentation on surveillance and labs: challenges and next steps in developing national surveillance systems on antimicrobial resistance (20 min) – WHO Surveillance of AMR country presentations (10 min) o MoH Cambodia o MoH Lao PDR 12:30-13:30 Lunch 13:30-14:30 Session 9 – Plenary: Infection prevention and control and surveillance systems that can make a difference Infection Prevention and control (15 min followed 5 minute for questions)- Dr Kayoko Hayakawa, Japan AMR Surveillance in human health (15 min followed by 5 minute for questions) – US CDC AMR surveillance in animal health (15 min followed by 5 minute for questions) – MARD, Viet Nam 14:30-15:00 Coffee break 15:00-17:00 Site Visits Site visit 1: Antimicrobial stewardship programme in a hospital Site visit 2: Animal farm End of day 2 Day 3. 20 January 2017 8:30- 9:00 Report back from site visits Plenary Discussion Recap of Day 2 - Dr Vanchinsuren Lkhagvadorj, WHO
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9:00-10:00
10:00-10:15 10:15-11:00
11:00-12:30
12:30-13:30 13:30-14:30
14:30-16:30 1. 16:30
Session 10 – Panel discussion: Sustaining actions – systems support to control antimicrobial resistance Introductory presentation: Framing of AMR as a development issue in the context of UHC, One Health and the SDGs (10 min) – Dr Vivian Lin, WHO Panel discussion: Moderator: Dr Socorro Escalante, WHO Panel topic: To identify the systems/structures and legal frameworks that are essential to sustaining multisectoral actions against antimicrobial resistance o Governance o Systems elements to sustain action against antimicrobial resistance o Regulatory support o Levels of intervention/engagement Panel members: OUCRU, Dr Susan Luu (Australia), Dr Vivian Lin (WHO), Dr Yooni Oh (OIE), Dr Katinka de Balogh (FAO) Coffee break Session 11 – Plenary: Global support to accelerate implementation of national action plans Presentation by the Center for Disease Control (CDC) (10 min) Presentation by the Fleming Fund (10 min) Presentation by the Global Antibiotic Resistance Partnership (GARP) (10 min) Plenary discussion Session 12 – Group work: Country planning for the next steps for implementation of national action plans on antimicrobial resistance Group 1: Cambodia Group 2: Lao PDR Group 3: Viet Nam Plenary – reporting back from group work per country Lunch Closing session Recap of meeting and key recommendations Summary remarks Open for bilateral discussions End of the Meeting
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