Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018: an update on two years implementation of national action plans

iSituational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Report 2018 An update on two years of implementation of national action plans

Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Report 2018 An update on two years of implementation of national action plans Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 ISBN: 978-92-9022-702-1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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Printed in India vCONTENTS Acknowledgements vi List of acronyms vii Foreword ix Executive summary xi Background 1 Recent relevant initiatives and developments in the Region 2 Intercountry meetings to review situation of NAP implementation in the Region 6 Results of situational analysis of NAP implementation 10 General trends in NAP implementation 10 Trends specific to focus areas 14 Conclusions 28 Way forward and recommendations 31 Key recommendations to address main challenges of AMR containment in the Region 31 Way forward for WHO and its regional Triparte partners 34 Country profiles 36 Bangladesh 36 Bhutan 43 DPRK 49 India 55 Indonesia 62 Maldives 70 Myanmar 77 Nepal 83 Sri Lanka 90 Thailand 98 Timor-Leste 105 Annex 1: List of focus areas and indicators assessed 115 Annex 2: Situation analysis Tool 2018 (WHO Regional Office for South-East Asia Region) 117 Annex 3: List of participants 124 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 vi Acknowledgements The South East Asia Regional Office of WHO (WHO-SEARO) wish to express their appreciation to all those whose considerable work in preparing for, and facilitating, the meeting, and reviewing this report efforts made this publication possible. This was a significant demonstration of the value of the Tripartite plus UNEP in working together to understand the complexity of antimicrobial resistance and its management and the inputs from the partners below is gratefully acknowledged. FAO HQ - Henk Jan Ormel, Senior Veterinary Policy Advisor FAO Regional Office for Asia and the Pacific - Katinka de Balogh, Senior Animal Health and Production Officer - Mary Joy Gordoncillo, AMR Regional Surveillance Coordinator OIE - Pennapa Matayompong, Programme Coordinator, Sub-regional Representation for South East Asia - Pasang Tshering, Consultant, Regional Representation for Asia and the Pacific UNEP Asia - Kakuko Nagatani-Yoshida, Regional Coordinator for Chemicals, Waste and Air Quality - Masato Motoki, Environment and Health Officer - Montira Pongsiri, Senior Research Associate WHO HQ - Elizabeth Tayler, Technical Officer, AMR Secretariat - Pravarsha Prakash, Technical Officer, AMR Secretariat The technical advice of Visanu Thamlikitkul, Director of WHO Collaborating Centre for AMR Prevention and Containment at the Faculty of Medicine Siriraj Hospital, Mahidol University and Viroj Tangcharoensathien, Senior advisor to the International Health Policy Programme (IHPP), Ministry of Public Health in Thailand is gratefully acknowledged. The meeting would not have been possible without the financial support of the United States Agency for International Development, USAID (Grant US -2016 1054 – Amendment 28 - One health surveillance of AMR in Asia) and the Government of Canada (Grant arrangement between Canada DFATD and WHO – D004200 – Combating Antimicrobial Resistance) and we are grateful for this but also the on-going technical advice from Dan Schar, Senior Regional Emerging Infectious Diseases Advisor, USAID and Sudarat Damrongwatanapokin Regional Animal Health Advisor, USAID. vii List of acronyms AAW Antibiotic Awareness Week AMR antimicrobial resistance AMS AMR stewardship AMSP AMR stewardship programme AMU antimicrobial use API active pharmaceutical ingredient AR antibiotic residues CDSCO Central Drugs Standard Control Organization DRA drug regulatory authority EPI expanded programme on immunization EQAS external quality assurance system ESBL extended-spectrum beta lactamases EWS early warning system FAO Food and Agriculture Organization GAP global action plan GAP-AMR global action plan on antimicrobial resistance GDP good distribution practices GLASS Global Antimicrobial Resistance Surveillance System GMP good manufacturing practices GPP good pharmacy practices HAI health-care-associated infection HiB haemeophilus influenza B HIV human immunodeficiency virus IEC information, education and communication IPC infection prevention and control JANIS Japanese Nosocomial Infection Surveillance System LMIC lower-middle income country MoH Ministry of Health M&E monitoring and evaluation MoU memorandum of understanding NADFC National Agency of Drug and Food Control NAP national action plan NAP-AMR national action plan on antimicrobial resistance NRA national regulatory authority Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 viii NGO nongovernmental organization OTC over-the-counter OIE World Organisation for Animal Health – Office International des Epizooties PCV pneumococcal conjugate vaccine R&D research and development SEA South-East Asia SEARN South-East Asia Regional Network SDG sustainable development goal SOP standard operating procedures ToR terms of reference UHC universal health coverage UNEP United Nations Environment Programme USAID United States Agency for International Development WASH water, sanitation and hygiene WHA World Health Assembly WHO World Health Organization ix Antimicrobial resistance (AMR) has been on the rise globally. One of the biggest concerns in modern medical science relates to resistant bacteria, due to which even common respiratory infections, skin sores and diarrhoea can become untreatable and place millions at risk. Experts warn that if steps are not taken by 2050, one in six deaths might be attributable to drug-resistant strains of tuberculosis, malaria, human immunodeficiency virus (HIV) and certain bacterial infections. If the current situation continues unchecked, AMR could result in a decline of 1.1–3.8% in the annual global gross domestic product (GDP), and could have a major impact on global poverty. At the United Nations General Assembly in New York in September 2016, global leaders committed themselves to fighting AMR. Despite the fact that they had come together, challenges persisted as national health priorities were influenced by different country contexts. Since 2010, WHO has taken steps to further the work on AMR in the Region. A global Tripartite partnership for One Health was signed with the Food and Agriculture Organization (FAO) and World Organisation for Animal Health (OIE) to provide a strategic vision and see to sharing of responsibilities to address health risks at the human– animal–environment interface. This was reinforced with the signing of an Memorandum of Understanding (MoU) in 2018, with details on combatting health risks at the health-care-associated infection (HAI) interface in the context of the One Health approach, and including AMR. In the last two years, the work initiated in 2010 has gained momentum with high-level advocacy meetings setting the stage for stakeholder engagement, donor support and technical activities for AMR containment. A situation analysis tool developed in 2016 provided technical guidance for assessing the functionality of the measures and capacity to contain AMR in the Region. This was followed up in 2018 with two intercountry meetings in Bangkok, where Tripartite members and Member States reviewed implementation and assessed the progress made in the two years since the last situation analysis in 2016. This report provides a synthesis of the discussions and an update on the status of the national action plans (NAP) in Member States. More recently, the Interagency Coordination Group (IACG) on AMR, co-chaired by the UN Deputy Secretary General and the WHO Director General, recommended building a partnership that goes beyond the Foreword Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 x Tripartite.i The renewed prioritization of this issue, along with binding commitments at the national, regional and global levels, will see stronger leadership and political buy-in, placing greater accountability for progress on AMR with individual countries. While we commend the IACG initiative for a global governance structure, we believe that global governance will need a relay at the regional level, identifying clear actions and translating global recommendations into implementation. We hope we can sustain funding to the interventions above, with the support of valued partners such as the United States Agency for International Development (USAID) and UK’s Fleming fund to fight AMR and save millions of lives. Poonam Khetraphal Singh Regional Director WHO South-East Asia Region i http://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_Future_global_governance_for_ AMR_120718.pdf xi Executive summary Ever since antibiotics were developed in the 1940s, scientists have warned that their improper use will lead to bacterial resistance. On the basis of the data presented in WHO’s Global Health Estimates, by the year 2050, about one in six deaths could be due to drug-resistant strains of tuberculosis, malaria, HIV and bacterial infections. WHO’s efforts to work with Member States to develop their national action plan on antimicrobial resistance (NAP- AMR) Since 2010, WHO has worked with FAO and OIE in a global Tripartite partnership for One Health to provide a strategic vision and ensure sharing of responsibilities to address health risks at the human–animal– environment interface. The Tripartite coordinated the development of a common multipronged regional action plan in support of countries, highlighting priority issues of governance and multisectoral coordination, capacity-building, gaps in knowledge and strengthening of systems. The announcement of the global action plan against antimicrobial resistance (GAP-AMR) in 2015 was followed by advocacy initiatives at the global and regional levels by WHO and the Tripartite, calling for the development of comprehensive NAPs-AMR that were aligned to strategic objectives and implemented using the One Health approach. It also provided technical support for developing and monitoring the progress of Member States with respect to their NAPs- AMR. Situational analysis of 2016 As a first step in implementing the AMR prevention and containment efforts in the Region, a situational analysis was initiated by the Regional Office in 2016. The findings culminated in a roadmap providing clear guidance on initiatives that Member States need to put in place to achieve sustainable AMR containment. By mid-2017, all 11 Members States had prepared NAPs and initiated programmes. These varied according to each country’s context and national health priorities. While the higher-income countries focused on emerging infectious disease outbreaks and AMR, the lower- income countries viewed AMR as an abstract concept, looking instead to strengthen local health systems to address endemic and ‘neglected’ diseases. Not having accurate national estimates on the AMR burden limited many countries, particularly those in the low- and middle-income category (LMIC), in the matter of making a case for substantial investment in containing AMR. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 xii Bangkok meetings and situational analysis of 2018 In 2018, two back-to-back follow-up meetings were held in Bangkok to assess progress and identify gaps and challenges in NAP implementation in the Region and suggest actionable recommendations. The meetings brought together country-led intersectoral teams, comprising representatives from the national drug regulatory authority (DRA), national referral laboratory, AMR stewardship programme (AMSP) and national officers in charge of the human and animal health sectors and environment sectors from the Member States, in addition to technical experts from FAO, Situational analysis tool of 2018 1. The advanced tool used for the situational analysis and monitoring of AMR was the same as that used by the Regional Office in 2016. 2. The tool was used to conduct system-wide analysis of AMR prevention and containment programmes, focusing on seven areas from the 2016 tool (NAP aligned with the GAP- AMR governance; awareness-raising; national AMR surveillance system; rational use of antimicrobials and surveillance of use/sales; infection prevention and control (IPC) and AMR stewardship; research and innovation; and One Health engagement. Further, it added the eighth focus area of overarching coordination mechanisms for One Health engagement. 3. It assessed progress on 30 indicators as a proxy for strategic interventions/programmes across eight focus areas and introduced 10 additional indicators. 4. Phase 3 or initial implementation was used as a cut-off for assessing progress. This is because this is one of the most challenging phases for programmes, especially in the context of developing countries, since it signifies an important shift from planning and identification of resources (Phases 1 and 2) to the initiation of implementation with political commitment and support (Phase 3 and above). OIE, United Nations Environment Programme (UNEP) and WHO collaborating centres from the Region. The situational analysis and review of implementation was carried out using the participatory methodology of guided discussion and conducted jointly by national stakeholders and WHO in collaboration with FAO, OIE and UNEP representatives. The national stakeholders assessed themselves with supporting evidence and justification on each of the indicators under individual focus areas, documenting strengths, challenges and implementation gaps. xiii Assessing the progress of a country The 2018 tool assessed the progress of NAP-AMR implementation based on 30 indicators as a proxy for strategic interventions/programmes across eight focus areas. These included 20 initial indicators (from the 2016 situational analysis tool) and 10 newly introduced indicators. For the purpose of analysis, Phase 3 or initial implementation was used as the cut-off for assessing the progress as it is an important milestone that signifies an important shift from planning and identification of resources (Phases 1 and 2) to initiation of implementation with political commitment and support (Phase 3 and above). Country progress was defined by the proportion of indicators that reached Phase 3 and above and was calculated for each country (followed by the calculation of median progress, i.e. median of country progress) in 2016 and 2018. The progress against individual indicators was assessed as the number of countries that achieved implementation of the level of Phase 3 and above by 2018. Results of the situational analysis, 2018 The situational analysis of 2018 revealed significant progress in the implementation of NAPs across different focus areas and their indicators in the Member States in the preceding two years. Based on the original 20 indicators, median country progress was significantly higher at 55% in 2018 (i.e. 50% of the countries had at least 55% of the 20 initial indicators that reached Phase 3 and above); progress against the same indicators in 2016 was 25%. On the basis of all 30 indicators (including the 10 new indicators introduced in the situational analysis tool of 2018), the median country progress in 2018 was 40%. In terms of how the indicators improved in countries, 17 out of the 20 indicators assessed in 2016 showed progress in 2018. The maximum progress was made in sanitation and hygiene programmes in community settings (10 countries in 2018), raising of awareness among the general public (nine countries in 2018), education and training (nine countries in 2018), NAP-AMR and governance structure (eight countries), regulations dealing with antimicrobials and active pharmaceutical ingredients or APIs (eight countries in 2018), strengthening of the national laboratory network, surveillance of antimicrobial use and sales among humans, and regulation of over- the-counter (OTC) sales (seven countries for each indicator in 2018). Implementation remained the same in “IPC in health-care settings”, whereas there was a decline in the number of countries in the case of “national AMR containment policy” and “AMSP in health-care settings”, mainly due to recalibration of earlier assessments. None of the countries was able to demonstrate initial implementation of early warning systems in the two years. As for the indicators newly assessed in 2018, none of the countries had implemented national policy/ regulatory frameworks for the controlled release of antibiotic residues (AR) in the environment. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 xiv Similarly, none had a platform for sharing AMR data across sectors or awareness and education programmes for the environment sector. All Member States achieved >Phase 4 or full operations in at least one indicator in 2018. Thailand emerged as a leader, with 14 indicators in Phase 4 and above. It was followed by Sri Lanka (9), Bangladesh (7) and Indonesia (6). The Democratic People’s Republic of Korea (DPRK) (1) and Timor-Leste (2) had the least number of indicators in full operation. Some continuing challenges The overall findings showed the animal health sector has made less progress across different focus areas and indicators. Limited systemic capacity of the animal health sector and lack of resources can explain some of the gaps in progress. This could impact One Health engagement and effective multisectoral collaboration. The environment sector, in particular, is less integrated across all focus areas and indicators, and this probably reflects a lack of clarity in the collaborative frameworks that necessitate their involvement. In a majority of the countries, implementation of AMR surveillance in the human health sector has not been initiated so far. It is lagging more in the animal and environment sectors. Similarly, AMR/ antimicrobial use (AMU) surveillance, IPC in health-care facilities, HAI surveillance and AMSP in most countries in the Region have failed to reach initial implementation in the last two years. None of the countries started initial implementation of early warning systems during this period. An in-depth analysis revealed a lack of policies, standards and guidelines which, in turn, lead to an inability to highlight the relevance of these activities in the resource-constrained Region. A key challenge faced by countries relates to having in place effective operational plans and regulatory frameworks that could be suitably adapted to AMR containment efforts. Most countries in the Region are yet to put together a strategic research agenda that is relevant to current policies and programmes, and address implementation challenges facing AMR containment efforts. Recommendations and next steps Strengthening governance and multisectoral collaboration is a priority, as is expanding awareness on AMR (emphasized as a continuous effort targeting different sectors and population groups as well as through academic curricula and training for students and working professionals). To initiatite and improve standardized and robust AMR/AMU surveillance across sectors, it was agreed that WHO and its Global Antimicrobial Resistance Surveillance System (GLASS), and the Tripartite partners must extend support as a matter of priority, providing technical support and guidelines. A key recommendation that resonated with all Member States was to standardize and implement IPC and antimicrobial stewardship programmes nationwide by involving hospital personnel, NGOs and key influencers in the community. To avoid the irrational use and resale of xv antimicrobials, it was also agreed by all Member States that regulations to monitor pharmacies and online outlets would be necessary. Further, checking the import of medical products for public and animal health sectors by promoting regulatory cooperation in South East Asia Regional Network (SEARN) that is more acceptable and innovative would strengthen AMR containment. These efforts would then drive the One Health agenda. It was agreed that the regional tripartite partners and UNEP will continue to support the implementation of NAPs-AMR in Member States by providing evidence-based technical guidance customized for each country. Going forward, the momentum thus achieved will be sustained through stronger multisectoral collaboration, including the creation of platforms that can enable joint planning, exchange of surveillance information and sharing of resources.

1Background Antimicrobial resistance is a global public health concern that has significant health and financial consequences. The prevalence of AMR been rising steadily and in many parts of the developing world, the levels of increase are considered “dangerously high”. The developing countries are more vulnerable than others due to their large population, coupled with a lack of financial, technical and human resources to deal with the high burden of infectious diseases. 10 million deaths may be attributed to AMR by 2050 at the global level and nine million in developing countries, with 4.7 million in Asia, 4.2 million in Africa and 392,000 in Latin America.1 The 11 Member States of the Region are Bangladesh, Bhutan, DPRK, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. They are lower-middle income countries (LMICs), which are home to 1.9 billion people. Although the Region has made steady social and economic progress, a large proportion of the population continues to live in poverty. Inadequate housing and sanitation accelerate person-to-person, and environmental, spread of resistant pathogens and genes. Antibiotics are widely used in the Region for therapeutic and non- therapeutic reasons in human beings, animals, aquaculture and agriculture, including for the promotion of growth. This inevitably leads to the presence of antibiotic residues in the environment, paving the way for bacteria to develop resistance through selective pressures. Qualitative risk analysis suggests that this Region is probably at the highest risk globally for the emergence and spread of AMR.2 According utmost priority to the issues related to AMR, the Region has developed comprehensive policies and adopted several Regional Committee resolutions on the prevention and containment of AMR. These include: i. A series of high-level advocacy meetings held to help set the stage for the engagement of stakeholders, support from donors and technical activities for AMR containment. ii. A situational analysis tool prepared in 2016 to provide technical guidance for assessing functionality and capacity in terms of governance, policy and 1 Review of antimicrobial resistance. Tackling drug-resistant infections globally: final report and recommendations. Chaired by Jim O Neil. May 2016 [http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf] 2 One Health approach to tackle antimicrobial resistance in South-East Asia. Poonam Khetrapal Singh, regional director BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3625 (Published 05 September 2017) Cite this as: BMJ 2017;358: j3625 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 2 systems available to contain AMR (used in 10 of 11 Member States). iii. The situational analysis was used to create a regional roadmap to help guide the Member States in developing their national AMR prevention and containment programmes. iv. A workshop was held in 2016, for all Member States, to review the progress of planning and implementation status with respect to NAP-AMR. This was combined with in-country review visits. The Regional Office developed a roadmap to assist Member States to develop their national AMR prevention and containment programmes and to implement NAP. The roadmap proposed five phases of development based on activities implemented as part of the NAP (Fig 1). v. Collaboration was initiated with FAO and OIE as a follow- up to the 2016 meeting and the development of NAP-AMR to hold intercountry meetings to: – review the implementation of NAP-AMR; – identify challenges to the containment of AMR; – assess the usefulness of the situational analysis tool in supporting NAP implementation; and – explore the flexibility of the tool to expand and include agriculture, aquaculture and environmental sectors in alignment with the One Health approach. Recent relevant initiatives and developments in the Region After the announcement of the GAP-AMR, SEA Region has taken serious note of its high vulnerability. Responding to the situation, it has translated the GAP-AMR into a public health priority and backed it with strong advocacy and policy initiatives. These developments have highlighted the political commitment of the regional leadership in this area. There have been important events and initiatives since the last situational analysis, as shown in Box 1. A multipronged strategic approach has been adopted, and there has been a wide range of policy proclamations, advocacy meetings and statements. Multisectoral coordination mechanisms have been put in place, efforts have been made to raise awareness efforts, and technical support has been provided to countries for generating policy- relevant evidence and monitoring of AMR containment efforts. 3Fig. 1. Roadmap for action on AMR in WHO SEA Region, 2016 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 4 BOX 1. Special initiatives and developments in SEA Region in 2017–18 Policy statements i. “Adopting an integrated approach to make progress towards universal health coverage (UHC) and ensuring access to effective treatment of infectious diseases while reducing risk of AMR”: Outcome of a high-level meeting on “UHC as a tool to combat infectious diseases” held on 30–31 May 2018 in Tokyo, Japan. ii. “Improving prevention, diagnosis and clinical management of sepsis and promoting AMR containment initiatives”: adopting the 70th WHA resolution in May, 2017. Technical support for policy relevant evidence i. Participation in Global antimicrobial surveillance system (GLASS): Encouraging Member States to participate in GLASS; nine out of 11 countries enrolled in GLASS and started to prepare for submission of surveillance data. ii. Scientific and literary work to support AMR containment: In 2017, a publication titled “Situation Analysis on AMR in SEAR” was released during the 70th Regional Committee meeting at Maldives, serving as baseline data for national AMR control programmes to measure progress. Other developments included: - DPRK followed Maldives’ example and undertook a situation analysis. - Regional AMR risk assessment was conducted and the result was published in the British Medical Journal in 2017, presenting initiatives from India, Indonesia and Thailand. - Priority intervention areas were identified, and pilots initiated within the framework of the NAPs on the basis of baseline risk assessment. The findings from these pilots will form the basis of national level programms to strengthen AMR surveillance and control. iii. WHO-led key projects undertaken proposed and approved: - An extended-spectrum beta-lactamases (ESBL) pilot project was initiated in Indonesia in 2017 as part of the regional integrated surveillance project. India and Nepal agreed to start the project by 2018-19 - An environmental surveillance and study on the role and impact of AMR on the environment was commissioned, on the basis of a recent WHO study: “Snapshot survey of AMR in East Kolkata Wetlands, India”. - Studies were conducted on a six-year retrospective analysis of antimicrobial consumption data in several Member States to determine the extent and pattern of use of antibiotics. iv. Adopting a regional approach: The approach was adopted through a SEARN platform that could help control and regulate the quality of antibiotics sold in the Region in human and animal sectors. v. Integrated surveillance: Proposing an integrated surveillance to be strengthened combining surveillance in humans with animals and in the environment. vi. Technical guidance: Extending technical guidance to build lab-supported human AMR surveillance in Member States. 5Multisectoral coordination mechanisms Developing NAP-AMR in all Member States: Available in WHO library at http://www.searo.who.int/entity/ antimicrobial_resistance/national-action-plans/en/. Strengthening coordination mechanisms: Multiple sectors were drawn in to promote intersectoral coordination at the national level and to coordinate bi-regional (SEA and Western Pacific) activities related to AMR containment in collaboration with the Regional Tripartite members (FAO & OIE). Constituting an AMR coordination group: In 2017, coordination mechanisms were established between departments in the Regional Office, led by the Senior Advisor to the Regional Director with a view to enabling comprehensive planning and engagement across sectors for AMR containment and utilizing the available resources and expertise in the Region optimally. Advocacy and awareness initiatives i. Participating actively in a regional workshop on AMR in SEA, in Penang, Malaysia, on 26-28 March 2018: It provided a platform to share lessons and experiences on how Asian countries have responded to the AMR crisis and how these can lead to evidence-based decisions and initiatives to tackle the issue. ii. Holding World Antibiotic Awareness Week: Since 2015, celebrations are held every November to improve awareness and understand AMR through effective communication, education and training. Key message in 2017: Seek advice from qualified health-care professional before taking antibiotics. Key message in 2018: Think twice. Seek advice. Misuse of antibiotics puts us all at risk. Monitoring AMR containment efforts i. Completing AMR self-assessment process: All countries in the Region participated in a global self- assessment process and the data was updated by June 2017. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 6 The WHO Regional Office for South- East Asia is committed to supporting periodic situational analysis activities across the Region. It also provides technical support that may be needed in the areas of surveillance, laboratory capacity, human resources, impact assessment and research to combat AMR in close coordination with Tripartite experts. In the light of this commitment, two back-to-back intercountry meetings were organized from 23–27 July 2018 in Bangkok, Thailand. These were held jointly with the Tripartite partners (FAO and OIE) and UNEP to review the implementation of NAPs by the Member States. The meetings sought to build momentum towards the containment of AMR and a subsequent reversal of trends. General objective • Monitor progress and address gaps in the implementation of -NAPs-AMR in the Region Specific objectives • To review progress on the implementation of NAPs-AMR; • To review progress in the development of national programmes for the containment of AMR; • To share good practices and lessons learnt; • To identify gaps, barriers and challenges in the implementation of AMR-NAPs and possible solutions and enablers; and • To make recommendations for effective implementation, considering the progress made, and suggest additions to update NAPs. Methodology for situation analysis of NAP implementation The situation analysis, 2018 and review of implementation was carried out using the participatory methodology of Guided Discussion. Briefly, Guided Discussion is a “transformative” approach to public health research. As a participatory Intercountry meetings that had good representation used the Guided Discussion approach to undertake an exhaustive review that was inclusive and participatory. It built on the 2016 situational analysis to bring in a fresh perspective with more nuances and insights, enabling Member States to identify areas for strengthening cross-sectoral collaboration at the national level for AMR containment. Intercountry meetings to review situation of NAP implementation in the Region 7approach, it ensures the involvement of all relevant stakeholders, both marginal and dominant groups, and enables them to voice their opinions. Participation is empowering, i.e. it leads to a participant-initiated action agenda and empowerment to participate in policy change. Guided Discussion is particularly useful after the participants have gained knowledge and experience on the topic of interest. In a Guided Discussion, the facilitator stimulates thought and “draws out” information with the help of questions that have a specific purpose and clear meaning. The ideas, facts and agreements that emerge as a result of the discussion are recorded. The implementation review in the intercountry meetings was conducted jointly by the national stakeholders and WHO (the Regional Office and country offices), in collaboration with FAO, OIE and UNEP representatives. The latter facilitated the exchange with national stakeholders who assessed themselves with supporting evidence and justification on a set of indicators and focus areas (Annex 1). This was done using a list of core questions from the Situational analysis tool (Annex 2) that was an advanced version of the 2016 tool.' Once a consensus was reached between the national stakeholders and facilitators on the level of progress made in implementing NAPs during 2017–2018, the phase of implementation for that indicator was ascertained and recorded. This was followed by the documentation of the strengths, challenges and implementation gaps. Fig. 2. Review methodology adopted for conducting NAP implementation The use of the Guided Discussion approach at the intercountry meetings ensured that the review was more inclusive and participatory than the assessment methodology of 2016. The situational analysis in the latter was carried out during in-country visits by officials and consultants from the Regional Office, as well as experts and external consultants, through dialogue with national stakeholders. The involvement of experts from FAO, OIE and UNEP brought in a fresh perspective that widened the horizons beyond the Ministry of Health (MoH), enabling countries to identify areas for strengthening cross-sectoral collaboration at the national level for AMR containment. Mul stakeholder review • Performed jointly by naonal stakeholders and WHO • Naonal stakeholders assess themselves with supporng evidence and jusficaon Guided discussion • Elicits exchange between facilitators and stakeholders through use of core quesons • Consensus achieved on grading of phase of implementaon Themac analysis • Ascertains the phase of implementaon by focus area • Idenfies and summarizes strengths, challenges and implementaon gaps Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 8 Tool used for situational analysis and monitoring of AMR The situation analysis tool of 2018 was an improvement over the one used in 2016. As in the case of the 2016 assessment, the tool was used to conduct a system-wide analysis of programmes for the prevention and containment of AMR. Focus areas: The 2018 situational analysis tool focused on eight areas. Seven were included from the 2016 tool: (1) NAP being in line with GAP-AMR governance; (2) raising of awareness; (3) national AMR surveillance system; (4) rational use of antimicrobials and surveillance of use/sales (community-based); (5) infection, prevention control and AMR stewardship; (6) research and innovation; and (7) One Health engagement. An additional area, ‘Overarching coordination mechanisms for One health engagement’, was introduced in the 2018 tool. Indicators: The 2018 tool assessed the progress against 30 indicators as a proxy for strategic interventions/ programmes across eight focus areas. These included 20 old indicators and 10 new introduced indicators. The new indicators were: one indicator under focus area 5 on “Infection prevention and control”; three indicators under focus area 7 on “One Health engagement”; and six indicators under the newly introduced focus areas 8 on “Overarching coordination mechanism”. A list of the 20 old and 10 newly introduced indicators is given in Annex 1. Assessment of progress: For the purpose of this report, Phase 3 or initial implementation was used as the minimum threshold for assessing progress. Phase 3 is one of the most challenging phases for programmes, especially in the context of developing countries. It is an important milestone as it signifies a shift from the planning and identification of resources to the initiation of implementation. Only 20 indicators (from the situational analysis tool, 2016) were considered while calculating the proportion for measuring the progress of a country in 2016 and its median progress between 2016 and 2018. DPRK was excluded from this calculation as the country was not a part of the situational analysis in 2016. To assess the status of country progress in 2018, the proportion of indicators that reached Phase 3 and above was calculated for all 30 indicators. The progress of individual indicators was assessed as the number of countries that achieved an implementation level of Phase 3 and above in 2018. For indicators that were assessed in 2016 (baseline), the number of countries that were able to achieve an implementation level of Phase 3 and above in 2018 were compared to the baseline. Country progress was defined as the proportion of indicators that reached Phase 3 or above and was calculated for each country (followed by calculation of median progress, i.e. median of country progress in the years 2016 and 2018). 9Participant profile: Country-led intersectoral teams comprised representatives, one each from the national drug regulatory authority, national referral laboratory and AMSP, and national officers in- charge of human health, animal health and environmental sectors, from all Member States of the Region. The technical experts included those from FAO (Headquarters and Regional Office for Asia and Pacific), OIE and global and regional offices of UNEP, two WHO collaborating centres from the Region and all three levels of WHO that facilitated and coordinated the sessions. Partners such as the United States Agency for International Development (USAID), Mott MacDonald for UK Fleming Fund, Canada’s International Development Research Centre (IDRC) Asia Regional Office (New Delhi, India), and International Health Policy Programme of the Thai Ministry of Public Health actively participated. Limitations of the methodology Two significant limitations were noted in the methodology that was adopted. i. The analysis was primarily based on group discussions between national programme managers with facilitators providing an overview for each indicator. The approach and tool provided an opportunity to the national stakeholders to present perceived challenges and needs and for them to discuss the justification with external partners, such as FAO, OIE and WHO, to seek feasible and consensual recommendations. ii. Incremental phase-based evaluation helped national programme managers to gain an understanding of progress from one phase to the next phase. The review was primarily based on the understanding and interpretation of the national stakeholders. Though the group involved in analysing the situation was quite broad, it did not include all stakeholders, like civil society, NGOs, education sector experts and likewise, who would have had a bearing on the overall assessment. To replace performance assessment based on the review of select participants by an assessment based on the effectiveness of interventions, WHO is currently developing performance indicators to measure the impact of AMR containment activities to support the monitoring of NAP implementation. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 10 The 2018 situational analysis revealed significant progress in the implementation of NAPs by Member States in the preceding two years across the seven focus areas. Since face-to-face Guided Discussions ensured greater in-depth understanding of the situational analysis tool as well as assessment of the status of implementation among the national stakeholders there was consensus on revising downward progress against some of the indicators. The following sections describe the progress made. General trends in NAP implementation There were a few significant trends in the implementation of NAPs, both with respect to overall progress in countries and to progress in focus areas and specific indicators which help draw lessons from the process. Overall progress in countries In 2016, Bhutan, Indonesia and India reported the highest proportion of indicators reaching Phase 3 or above (country progress of 45%). Timor- Leste had no indicator in Phase 3 and above (0% country progress); the median of country progress was at 25%. In contrast, when the same indicators were assessed in 2018, the evidence of progress was more substantial, with median country progress at 55%, ranging from country progress at 95% in Thailand to 15% in Timor-Leste). Overall, 9 out of 10 countries made progress in the proportion of indicators in Phase 3 between and 2016 and 2018 (Fig. 3). On the basis of the 30 indicators (including the 10 additional indicators), the median country progress in 2018 was at 40% (maximum country progress at 83.3% in Thailand and minimum 16.7% in Nepal and Timor-Leste), compared to 25% (Fig. 4) Progress of focus areas and indicators Seventeen out of the 20 indicators assessed in 2016 showed progress in 2018 (Table-1). The maximum progress in terms of the number of countries in implementation Phase 3 and above was made in sanitation and hygiene programmes in community settings and establishing a functional National Regulatory Authority or Drug Regulatory Authority (10 countries in 2018), awareness among the general public (nine countries in 2018), education and training (nine countries in 2018), NAP-AMR and governance structure (eight countries), regulations of finished products and APIs (eight countries in 2018), national laboratory network strengthening, surveillance of use and sale in humans, regulation of OTC sales (seven countries in each indicator in 2018). The number Results of situational analysis of NAP implementation 11 Fig. 3. Progress of NAP-AMR implementation, 2016–18 Fig. 4. Progress of NAP-AMR implementation by country, 2016–18 20 45 0 45 45 10 15 25 25 30 0 25 60 50 0 60 65 40 35 20 80 95 15 5556.7 40.0 30.0 46.7 43.3 30.0 30.0 16.7 63.3 83.3 16.7 40.0 0 10 20 30 40 50 60 70 80 90 100 Bangladesh Bhutan DPRK* India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand TLS Median progress ) %( evoba dna 3 esahp ni srotacidni fo noitroporP 2016* 2018* 2018** Progress of NAP AMR implementaon, by country, SEAR (2016-18) 016*Progress assessed for 20 indicators based on Situaon Analysis tool 2016; Situaon Analysis was not conducted in DPRK in 2 and so progress not compared in 2018 ** Progress assessed for 30 indicators (10 newly introduced indicators) based on Situaon Analysis tool 2016 Progress of NAP AMR implementaon in SEAR (2016 18) 2016* 2018* 2018** *Progress assessed for 20 indicators based on Situaon Analysis tool 2016; Situaon Analysis was not conducted in DPRK in 2016 and so progress not compared in 2018 ** Progress assessed for 30 indicators (10 newly introduced indicators) based on Situaon Analysis tool 2016 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 12 Ta bl e 1. P ha se s of in di ca to rs in e ig ht fo cu s ar ea s fo r al l M em be r St at es o f t he R eg io n du ri ng th e si tu at io na l a na ly si s re vi ew o f A M R in 2 01 8 S. N o. Fo cu s ar ea a nd s ub in di ca to rs Ba ng la de sh Bh ut an DP R Ko re a In di a In do ne sia M al di ve s M ya nm ar N ep al Sr i L an ka Th ai la nd Ti m or -L es te 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 1 N at io na l A M R pl an a nd g ov er na nc e 1. 1 NA P in li ne w ith G AP -A M R 3 2 3 3 3 NA 3 2 2 3 4 2 3 2 2 2 4 3 5 3 2 2 2 Ra isi ng a w ar en es s 2. 1 Ca m pa ig ns to ra ise p ub lic a w ar en es s 4 3 4 3 3 NA 2 2 4 3 3 2 3 2 2 2 4 2 4 2 4 2 2. 2 Ed uc at io n an d tra in in g st ra te gi es fo r p ro fe ss io na ls 3 1 3 2 2 NA 3 2 3 3 3 1 3 2 1 2 3 1 5 3 3 1 3 N at io na l A M R su rv ei lla nc e sy st em 3. 1 Na tio na l h um an A M R su rv ei lla nc e 3 2 2 2 2 NA 3 2 2 2 2 2 2 2 4 3 4 3 5 3 2 1 3. 2 Na tio na l l ab or at or y ne tw or k st re ng th en in g 3 2 3 3 1 NA 4 2 1 1 2 1 4 2 3 3 5 2 5 4 1 1 3. 3 Ea rly w ar ni ng sy st em s 1 1 1 2 1 NA 2 2 1 NA 1 1 1 1 1 2 1 1 2 1 1 1 4 Ra tio na l u se o f a nt im icr ob ia ls an d su rv ei lla nc e of u se /s al e (c om m un ity -b as ed ) 4. 1 A na tio na l A M R co nt ai nm en t p ol icy fo r c on tro l o f hu m an u se o f a nt im icr ob ia ls; AM R st ew ar ds hi p 2 1 2 2 2 N A 2 3 2 4 2 2 1 1 1 2 2 2 3 2 2 1 4. 2 Na tio na l r eg ul at or y au th or iti es o r d ru g re gu la to ry au th or iti es 4 3 4 5 3 NA 4 4 5 4 4 3 3 3 4 3 4 2 3 2 2 1 4. 3 Su rv ei lla nc e of a nt im icr ob ia l u se a nd sa le s i n hu m an s 3 2 2 1 3 NA 3 3 3 3 3 2 2 2 1 3 3 1 4 2 2 1 4. 4 Re gu la tio n of fi ni sh ed a nt ib io tic p ro du ct s a nd ac tiv e ph ar m ac eu tic al in gr ed ie nt s ( AP Is) 4 3 4 4 3 NA 4 4 5 NA 4 2 2 2 2 2 3 2 4 2 1 2 4. 5 Re gu la tio n of O TC sa le a nd in ap pr op ria te sa le o f an tib io tic s a nd A PI s b y ph ar m ac ie s 4 3 5 5 1 N A 4 4 4 NA 4 2 2 2 2 3 4 2 4 2 2 1 5 In fe ct io n pr ev en tio n an d co nt ro l a nd A M R s te w ar ds hi p pr og ra m m e 5. 1 AM R st ew ar ds hi p pr og ra m m e in h ea lth -ca re se tti ng s 2 2 2 2 2 NA 1 3 3 3 1 1 2 2 1 2 2 1 4 3 1 1 5. 2 IP C pr og ra m m e in h ea lth -ca re se tti ng 2 2 2 3 3 NA 3 3 3 3 2 2 2 3 1 1 4 3 3 2 1 1 5. 3 Na tio na l H AI a nd re la te d AM R su rv ei lla nc e 2 2 2 4 3 NA 3 3 2 2 1 2 3 1 1 1 4 2 4 2 1 1 5. 4 Sa ni ta tio n an d hy gi en e 4 1 5 5 5 N A 3 4 4 NA 4 2 2 3 4 2 4 4 4 3 3 2 5. 5 Va cc in at io n 4 N A 1 NA 1 NA 3 NA 2 NA 1 NA 4 NA 2 NA 3 NA 3 NA 4 NA 6 Re se ar ch a nd in no va tio n 6. 1 R& D an d in no va tio n on A M R pr ev en tio n an d co nt ai nm en t a nd re se ar ch fu nd in g 2 2 2 2 1 NA 2 2 2 2 2 1 3 2 1 1 2 1 4 1 1 1 13 S. N o. Fo cu s ar ea a nd s ub in di ca to rs Ba ng la de sh Bh ut an DP R Ko re a In di a In do ne sia M al di ve s M ya nm ar N ep al Sr i L an ka Th ai la nd Ti m or -L es te 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 20 18 20 16 7 O ne H ea lth e ng ag em en t 7. 1 A na tio na l A M R co nt ai nm en t p ol icy a nd re gu la to ry fr am ew or k fo r c on tro l a nd re gi st ra tio n of u se in a ni m al se ct or 4 2 3 2 1 N A 2 2 3 2 1 2 1 1 1 2 4 3 3 2 1 1 7. 2 Na tio na l s ur ve illa nc e of A M R ,a nd u se a nd sa le o f an tim icr ob ia ls at n at io na l l ev el in th e ve te rin ar y se ct or AM U- 2 AM R- 2 2 AM U- 2 AM R- 2 1 AM U- 1 AM R- 1 N A AM U- 1 AM R- 2 1 AM U- 3 AM R- 3 2 AM U- 1 AM R- 1 3 AM U- 1 AM R- 1 1 AM U- 1 AM R- 2 2 AM U- 2 AM R- 3 1 AM U- 3 AM R- 3 2 AM U- 1 AM R- 1 1 7. 3 Bi os ec ur ity (i nf ec tio n pr ev en tio n an d co nt ro l) in th e an im al se ct or 3 2 2 2 3 N A 3 2 4 3 1 1 1 2 2 1 3 2 5 2 1 1 7. 4 AM R aw ar en es s g en er at io n an d ed uc at io n in th e an im al se ct or 2 2 3 2 1 NA 1 2 3 1 1 1 1 1 1 1 3 1 4 2 1 1 7. 5 A na tio na l A M R co nt ai nm en t p ol icy a nd re gu la to ry fr am ew or k to c on tro l r el ea se o f A R an d AM R in to th e en vir on m en t a nd m an ag em en t th er e in 1 NA 1 NA 1 N A 1 NA 1 N A 1 NA 1 N A 1 N A 2 N A 2 N A 1 N A 7. 6 Na tio na l s ur ve illa nc e of A R an d AM R in w as te w at er fr om m an uf ac tu re a nd h um an /a ni m al /f ish us e an d di sp os al in in st itu tio ns a nd th e ho m e 3 NA 1 NA 1 N A 1+ NA 1 N A 1 N A 1 N A 1 N A 1 NA 1+ N A 1 N A 7. 7 Ra isi ng a w ar en es s o n AM R an d ed uc at io n in th e en vir on m en ta l s ec to r 1 NA 1 NA 1 NA 1 NA 1 NA 2 N A 1 N A 1 NA 1 NA 2 N A 1 N A 8 O ve ra rc hi ng c oo rd in at io n m ec ha ni sm s fo r O ne H ea lth e ng ag em en t 8. 1 O ve ra rc hi ng A M R co or di na tio n m ec ha ni sm s be tw ee n al l r el ev an t s ec to rs 4 NA 3 N A 2 NA 2 NA 1 NA 2 NA 2 N A 2 NA 2 N A 4 NA 1 N A 8. 2 In clu sio n an d en ga ge m en t o f a ll re le va nt s ec to rs in th e NA P- AM R 2 N A 2 N A 1 NA 3 N A 2 N A 2 N A 2 NA 2 N A 2 N A 5 N A 3 N A 8. 3 A pl at fo rm a nd /o r m ec ha ni sm fo r s ha rin g of AM U m on ito rin g da ta fr om a ll re le va nt se ct or s 4 N A 2 N A 1 NA 1 N A 1 N A 1 N A 1 N A 1 NA 3 NA 3 N A 1 N A 8. 4 A pl at fo rm a nd /o r m ec ha ni sm fo r s ha rin g of A M R su rv ei lla nc e da ta fr om a l r el ev an t s ec to rs 2 N A 1 NA 1 NA 2 NA 2 N A 1 N A 2 NA 2 N A 2 NA 2 N A 1 NA 8. 5 AA W is n at io na lly c oo rd in at ed a nd c el eb ra te d, w ith in vo lve m en t o f a nd c on tri bu tio n fro m a ll re le va nt s ec to rs 4 N A 3 N A 1 NA 1 N A 1 NA 3 NA 5 N A 3 N A 2 NA 5 N A 3 NA 8. 6 A m ec ha ni sm fo r c o- sh ar in g of re so ur ce s f or A M R in iti at ive s in th e co un try 1 N A 1 N A 1 NA 1 NA 1 NA 2 NA 1 N A 1 NA 3 N A 3 N A 1 N A NA : N ot a ss es se d 1+ - Di sc us sio n in P ha se 2 a llo ca tio n in co nc lu siv e Ta bl e 1 co nt d. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 14 of countries achieving a level of implementation of Phase 3 and above remained the same in the indicator on “IPC in health-care settings”, whereas in the case of “national AMR containment policy” and “AMSP in health-care settings”, there was a decline in the number of countries, mainly due to recalibration of earlier assessment. None of the countries was able to demonstrate initial implementation of early warning systems in the two years. Ten additional indicators were introduced in the situational analysis tool of 2018. Seven countries were in Phase 3 and above with regard to the implementation of the “nationally coordinated AAW” and six countries in “vaccination”. In three countries each, “overarching coordination mechanism”, “inclusion and engagement of relevant sectors” and “platform for sharing AMU data” were at Phase 3 and above in 2018. None of the countries had implemented a national policy/regulatory framework for the controlled release of AR and AMR in the environment. Nor had any of the countries established a platform for the sharing of AMR data across sectors or initiated awareness and education programmes for the environment sector. All Member States were able to achieve > Phase 4 or full operations with regard to at least one indicator in 2018. Thailand was the leader, with 14 indicators in Phase 4 and above, followed by Sri Lanka (10), Bangladesh (7) and Indonesia (6); DPRK (1) and Timor-Leste (2) had the least number of indicators in full operation. Trends specific to focus areas Focus area 1: NAP in line with the GAP-AMR (Fig. 5) Indicator 1.1: NAP in line with the GAP-AMR/level of governance Five Member States (45%), namely, Bangladesh, Bhutan, DPRK, India, and Myanmar have developed their NAP in line with the GAP-AMR, including operational strategies with defined activities and budgetary provisions (Phase 3).However, though India has a NAP, the federal nature of the country requires the drawing up of state action plans. These are still being developed for the priority states to initiate decentralized implementation, Kerala being one of the first to develop an action plan. Fig. 5. Focus area 1: NAP in line with GAP-AMR 4 8 0 1 2 3 4 5 6 7 8 9 2016 2018 No o f c ou nt rie s (> p ha se 3 ) In Indonesia, the AMR working group has been established and its NAP is under development (Phase 2).1 In Nepal, the NAP has been prepared in line with the GAP- 1 On the basis of its discussion with the facilitators, the national team from Indonesia proposed a phased revision from Phase 3 in 2016 to Phase 2 in 2018 for this indicator. 15 AMR and is awaiting endorsement by the government (Phase 2). Timor Leste has developed a NAP-AMR, which includes an operational plan with defined activities and their respective budgets (Phase 2). Both Sri Lanka and Maldives have made significant progress in rolling out their NAP-AMR and scaled up activities across their respective countries (Phase 4). In Thailand, ongoing efforts have helped attain a phase of sustainable operations (Phase 5). Focus area 2: Raising awareness (Fig. 6) Indicator 2.1: Awareness campaigns directed at the public Fig. 6. Focus area 2: raising awareness 2016 2018 3 2 9 9 0 1 2 3 4 5 6 7 8 9 10 Awareness to public Education & training for professionals N o of c ou nt rie s (> p ha se 3 ) In six Member States (55%), namely, Bangladesh, Bhutan, Indonesia, Sri Lanka, Thailand and Timor-Leste, there were nationwide, government- led antibiotic awareness campaigns, targeting both the public and health professionals. The activities for this indicator were in the phase that entailed full operation (Phase 4). In three Member States (27%), i.e., DPRK, Maldives and Myanmar, campaigns and activities to raise awareness were conducted on a limited scale (Phase 3). In the remaining two Member States (18%), India and Nepal, few government- led activities were conducted in different parts of the country with a view to raise awareness of AMR. This resulted in the stage of programme installation even as initiatives to raise awareness were being planned (Phase 2). Indicator 2.2: Education and training strategies for professionals Content for training on AMR and related issues has been included in continuous professional development courses for health-care professionals and induction training organized by the eight Member States (73%) of Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Sri Lanka and Timor-Leste (Phase 3). Nepal: Proposals for the revision of the medical curriculum to include AMR-related content are under consideration (Phase 1)2 DPRK: This indicator is in the phase of programme installation since plans for professional training have been developed and proposals have been made for the initiation of annual training courses for health workers on AMR (Phase 2). Thailand: Concepts related to AMR have been incorporated in the pre- service training of all relevant cadres across sectors. Such training is regularly conducted as continuing professional development courses for all health-care professionals, and the performance is monitored and evaluated (Phase 5). 2 Following deliberations at the workshop, the phase for this indicator was revised from Phase 2 in 2016 to 1 in 2018, primarily for want of a clearly developed strategy for training health professionals. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 16 Focus area 3: National AMR surveillance system (Fig. 7) Indicator 3.1: National human AMR surveillance The system of national human AMR surveillance is well established and functional for monitoring AMR trends accurately and in a timely manner in Nepal and Sri Lanka (Phase 4). In Thailand, national AMR surveillance is regularly assessed and adjusted, and has been contributing data meaningfully to GLASS (Phase 5). Standardized national surveillance is operational at a limited number of sites in Bangladesh and India (Phase 3). As for the other six Member States (55%), i.e. Bhutan, DPRK, Indonesia, Maldives, Myanmar and Timor-Leste, guidelines have been developed for human AMR surveillance, but implementation is limited due to various constraints of skilled human resources, access to funds and data management (Phase 2). Indicator 3.2: Strengthening of national laboratory network In Bangladesh, Bhutan and Nepal, the national AMR reference laboratory is functional, the Clinical and Laboratory Standards Institute (CLSI) guidelines have been adopted as a reference standard and a quality assured laboratory network is operational at selected sites that are participating in the external quality assurance system (EQAS) (Phase 3). In India and Myanmar, a repository system and national EQAS have been set up at all surveillance sites (Phase 4). The laboratory network comprises laboratories both from the public and private sectors nationwide. Research is an integral component of laboratory surveillance, there being an established infrastructure, equipment and human resources dedicated to research-related activities. These positive steps helped Sri Lanka and Thailand to attain a stage of sustainable operations (Phase 5). In Indonesia and Timor- Leste, no national laboratory network has been established for AMR surveillance in the human sector, in the case of DPRK, there is limited information on international standards and antimicrobial sensitivity testing. Thus, the latter three Member States (27%) continue in the stage of exploration and adoption (Phase 1). Indicator 3.3: Early warning systems Early warning systems (EWS) have not been established (Phase 1) in nine of the 11 (82%) Member States.3 India and Thailand have developed plans for implementing early warning of emerging AMR, in line with international standards and pilot projects for EWS that have been initiated (Phase 2). Focus area 4: Rational use of antimicrobials and surveillance 3 Bhutan and Nepal agreed to revise the phase of progress from Phase 2 in 2016 to Phase 1 during 2018. 2016 2018 3 3 0 5 7 0 0 1 2 3 4 5 6 7 8 National AMR surveillance (humans) National Laboratory network Early warning system N o of c ou nt rie s (> p ha se 3 ) Fig. 7. Focus area 3: national AMR surveillance system 17 of use/sale [community-based] (Fig.8) Indicator 4.1: A national AMR containment policy for control of human use of antimicrobials A total of eight Member States (73%) are in the process of implementing the national AMR containment policy for control of the human use of antimicrobials (Phase 2). The national antimicrobial containment policy is under development in Myanmar (Phase 1). A national policy and guidelines for regulated use of antimicrobials are yet to be developed in Nepal (Phase 1). Thailand is currently focusing on the multidisciplinary expansion of the national policy with the potential to scale-up nationally (Phase 3). India is yet to initiate the implementation of its National AMR containment policy (Phase 2), while efforts are ongoing in Indonesia to initiate nationwide implementation (Phase 2). In Nepal, the national guidelines and policy for antimicrobial containment are yet to be developed (Phase 1).4 Indicator 4.2 National regulatory authorities National regulatory authorities (NRA) are fully operational (Phase 4) in six (55%) Member States and nationwide activities and outcomes are regularly shared with programme managers. There is a need to strengthen the NRAs in DPRK, Myanmar and Thailand, as these are in a phase of initial implementation (Phase 3). In Thailand, tools for quality assurance are in place and inspection is implemented, but the capacity for the enforcement of policies and regulation is limited. Timor-Leste needs to focus on NRA strengthening and capacity-building (Phase 2). In Indonesia, the National Agency of Drug and Food Control (NADFC) ensures compliance with 4 India revised its implementation phase from Phase 3 in 2016 to Phase 2 in 2018; Indonesia revised its implementation phase to Phase 2 in 2018 from Phase 4 in 2016; and Nepal assessed its implementation in 2018 as Phase 1 compared to Phase 2 in 2016. Fig. 8. Focus area 4: rational use of antimicrobials and surveillance of use/sale 2016 2018 2 7 3 3 4 1 10 7 8 7 0 2 4 6 8 10 12 National AMR containment policy; AMSP (humans) NRA/DRA Surveillance of use and sales (humans) Regulation of finished products and APIs Regulation of OTC sales N o of c ou nt rie s (> p ha se 3 ) Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 18 good manufacturing, distribution and pharmacy practices, in addition to evaluating safety, efficacy and quality aspects. These steps point towards the effective implementation of the programme with sustainable operations (Phase 5). In Bhutan, the NRA is fully operational but yet to ensure sustainability. The country aims to strengthen and build the capacity of the NRA at the national level through regulatory cooperation with SEARN (Phase 4).5 Indicator 4.3 Surveillance of antimicrobial use and sale among humans Six Member States (55%) are reported to have established a surveillance mechanism for antimicrobial use (AMU) and sales among humans that includes framing a policy and organizing a task force for the collection of production data (Phase 3). Bhutan, Myanmar and Timor-Leste are beginning to implement surveillance mechanisms for AMU (Phase 2). Nepal is yet to develop a surveillance mechanism (Phase 1), while Thailand’s surveillance mechanism is fully functional (Phase 4). Indicator 4.4: Regulation of finished antibiotic products and active pharmaceutical ingredients The regulation of finished antibiotic products and APIs is fully operational (Phase 4) in five Member States (45%). Myanmar and Nepal continue to develop regulations, as was the situation in 2016 (Phase 2), while DPRK is in the process of rolling out regulations at the national level (Phase 3). Sri Lanka already has regulations in place, though 5 Bhutan revised its implementation phase from Phase 5 in 2016 to Phase 4 in 2018. some areas such as inspection is limited, due to the lack of resources (Phase 3). The NADFC in Indonesia has reportedly attained the highest performance standards with sustainable operations (Phase 5). Indicator 4.5: Regulation of OTC and inappropriate sale of antibiotics and APIs by pharmacies The regulation of OTC and inappropriate sale of antibiotics and APIs by pharmacies has attained a state of full operation in six Member States (55%). In Bhutan, the regulations are fully operational nationwide, with regular monitoring and evaluation of implementation (Phase 5). Myanmar, Nepal and Timor-Leste are currently developing structures and making provisions for the allocation of resources to implement regulations on a nationwide scale. Strategic planning is in place for capacity building and the allocation of a budget to conduct activities (Phase 2). In DPRK, a beginning has been made to identify potential barriers in the implementation framework (Phase 1).6 Focus area 5: Infection prevention control and AMR stewardship programme (Fig. 9) Indicator 5.1: AMR stewardship programme in health-care settings India, Maldives, Nepal and Timor- Leste were found to be in the initial stages of establishing an AMSP in health-care settings (Phase 1). Bangladesh, Bhutan and Myanmar continue to establish their programmes, as was the case in 2016 (Phase 2), while DPRK and Sri 6 Nepal revised its implementation phase from Phase 3 during 2016 to Phase 2 in 2018. 19 Lanka have completed their core set of activities and are focused on implementing the programme with a potential to scale it up nationally (Phase 2). Specifically, Sri Lanka has developed national guidelines on IPC and geared infection control units in hospitals to support IPC activities by conducting the training of staff regularly. In DPRK, guidelines are available in health facilities for prescribing antimicrobials only after testing for susceptibility, which is conducted at each provincial hospital. Besides, the prevention of infection in health-care settings is a part of the national strategy. Indonesia continues to establish the programme in select health-care settings (Phase 3), as in 2016, while Thailand has scaled up its activities nationwide and progressed to full operations (Phase 4).7 Indicator 5.2: IPC programme in health-care settings Bangladesh, Bhutan, Maldives and Myanmar are focused on establishing IPC in health-care settings, with 7 India and Nepal revised their implementation phase to Phase 1 from Phase 3 and Phase 2, respectively, in 2016. the potential to scale up nationally (Phase 2).8 DPRK, India, Indonesia and Thailand have implemented IPC programmes in health-care settings across a limited number of sites in the country (Phase 3). In Sri Lanka, nationwide surveillance for methicillin-resistant staphylococcus aureus bacteraemia, hand hygiene, lower segment caesarean surgery with quarterly reporting of data to provincial hospitals indicate full operation of the IPC programme in health-care settings (Phase 4). Nepal and Timor-Leste are in the process of identifying potential barriers and setting up systems and frameworks to initiate IPC in health-care settings and combat AMR (Phase1). Indicator 5.3: National HAI and related AMR surveillance Bangladesh, Bhutan and Indonesia are establishing national-level programmes for hospital-acquired infection (HAI) and AMR surveillance (Phase 2). Three Member States (27%), i.e. Maldives, Nepal and 8 Bhutan and Myanmar revised phase-grading from Phase 3 in 2016 to Phase 2 in 2018. Fig. 9. Focus area 5: infection prevention and control and AMR stewardship programme 3 5 2 5 0 2 5 5 10 6 0 2 4 6 8 10 12 AMSP in healthcare settings IPC in HCS National HAI surveillance Sanitation & Hygiene Vaccination* N o of c ou nt rie s (> p ha se 3 ) 2016 2018 * New indicator introduced in situational analysis tool, 2018 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 20 Timor-Leste, are in the stage of initial exploration and the adoption of this indicator (Phase1), while DPRK, India and Myanmar have already attained the stage of initial implementation (Phase 3).9 In Sri Lanka, bacteriological testing of food and water samples is conducted regularly, along with well-established national surveillance of water quality; also, mechanisms are in place to ensure compliance with hand hygiene that is reported regularly to the central authorities (Phase 4). In Thailand, HAI surveillance has been set up, with regular reporting on AMR (Phase 4). Indicator 5.4: Sanitation and hygiene Bhutan and DPRK have well established WASH and waste disposal programmes (Phase 5). Six Member States (55%), i.e. Bangladesh, Indonesia, Maldives, Nepal, Sri Lanka and Thailand, have adopted large-scale nationwide sanitation and hygiene activities to combat AMR, and are in the phase of full operation (Phase 4). In Thailand, potable tap water supplies are available in health-care facilities, and campaigns on sanitation and hygiene are conducted at regular intervals. India and Timor-Leste have still not engaged in nationwide sanitation and hygiene activities that are relevant to reverse AMR trends (Phase 3).10 Indicator 5.5: Vaccination This indicator was added to the situational analysis tool to ensure a renewed focus on vaccination as 9 Bhutan revised its implementation phase from Phase 4 in 2016 to Phase 2 in 2018, and Maldives from Phase 2 in 2016 to Phase 1 in 2018. 10 India revised its implementation phase from Phase 4 in 2016 to Phase 3 in 2018, and Myanmar from Phase 3 in 2016 to Phase 2 in 2018. a strategy to curb AMR. It has been observed that vaccine technology is available but is underused for the prevention of bacterial infections, particularly those caused by organisms resistant to antimicrobials. Bhutan, DPRK and Maldives are currently exploring the inclusion of pneumococcal conjugate vaccine (PCV) in their respective routine immunization schedules (Phase1). Indonesia and Nepal are now beginning to implement the inclusion of PCV in routine immunization (Phase 2). Three Member States (27%), i.e. India, Sri Lanka and Thailand, have included PCV in their expanded programme on immunization (EPI) schedule (Phase 3), and three other Member States (27%), i.e. Bangladesh, Myanmar and Timor-Leste, have introduced PCV nationwide (Phase 4). Focus area 6: Research and innovation (Fig. 10) Indicator 6.1: R&D and innovation on AMR prevention and containment (+ research funding) Six Member States (55%), Bangladesh, Bhutan, India, Indonesia, Maldives and Sri Lanka, have plans to foster research and development and innovation on AMR prevention and containment. A strategic research agenda has been developed and policies planned to support research that assists the implementation of NAP-AMR, along with funding from various national and international resources tapped for conducting research (Phase 2). The Member States (27%) of DPRK, Nepal and Timor-Leste are yet to develop specific policies related to research and development and innovation for AMR containment and 21 prevention (Phase 1). In Myanmar, the existing policies and structures support activities related to research on the prevention and containment of AMR (Phase 3), while in Thailand, research is integral to supporting evidence-based policy decisions. The country has well-established infrastructure, equipment, skilled manpower and funds for research and development from domestic and international donors (Phase 4). Fig. 10. Focus area 6: research and innovation 0 2 0 2 4 6 8 10 2016 2018 N o of c ou nt rie s (> p ha se 3 ) Focus area 7: One Health engagement (Fig. 11) Indicator 7.1: A national AMR containment policy and regulatory framework for control of use for animals, and their registration for use The DPRK, Maldives, Myanmar, Nepal and Timor-Leste are yet to develop a national AMR containment policy and a regulatory framework for control of the use of antimicrobials in the veterinary sector (Phase 1). India has planned a drug regulatory authority for the veterinary sector and issued an advisory for prudent use of antimicrobials for the treatment of animal diseases (Phase 2). Bhutan, Indonesia and Thailand have progressed from Phase 2 to Phase 3 by developing a regulatory framework and initiating the implementation of AMR containment in the veterinary sector. As for Bangladesh, the country’s legal framework prohibits the use of antimicrobials in animal feed, and the classification of the use of antimicrobials includes drugs for limited use in “watch and reserved” category. In Sri Lanka, the regulatory framework closely monitors the importation of antimicrobials and ensures that licensing is renewed periodically. Bangladesh and Sri Lanka have made efforts to bring this indicator in a phase of full operation in the last two years (Phase 4).11 Inadequate infrastructure, the absence of skilled manpower, and gaps in operational guidelines and laboratory standard operation procedures have contributed to varying levels of AMR containment activities in most of the Member States in the Region. Indicator 7.2: National surveillance of AMR and use and sales of antimicrobials at national level in the veterinary sector AMR surveillance in the veterinary sector has been initiated in accordance with the national plans in Indonesia, Sri Lanka and Thailand (Phase 3). National plans have been developed, but with limited capacity for implementation of AMR surveillance in Bangladesh, Bhutan and India (Phase 2). No national policy/guidelines have been developed for AMR surveillance in the veterinary sector in DPRK, Maldives, Myanmar, Nepal and Timor-Leste, resulting in a stage of exploration and adoption of this indicator (Phase 1). However, project-based AMR 11 Nepal revised its implementation phase from Phase 2 in 2016 to Phase 1 during 2018. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 22 surveillance is ongoing in Myanmar.12 In Maldives, though the AMR containment policy includes AMR surveillance in animals, no activities have been conducted so far due to limited infrastructure, the absence of skilled manpower, and gaps in operational guidelines and laboratory standard operation procedures. Five Member States (45%), i.e. DPRK, India, Maldives, Myanmar and Timor- Leste, are yet to develop guidelines for the surveillance of AMU. Also, monitoring guidelines for sales in the veterinary sector are yet to be developed (Phase 1).13 Though the NAP outlines AMU surveillance and monitoring activities in Myanmar, these are yet to be initiated. There is limited capacity for surveillance 12 The Myanmar Pig Partnership, funded by the Zoonoses and Emerging Livestock Systems (ZELS) and led by the University of Cambridge, is an interdisciplinary research project exploring the disease risk accompanying the changing pig production and consumption patterns in Myanmar. It covers AMR and AMU. 13 Maldives revised its implementation phase from Phase 3 in 2016 to Phase 1 in 2018. of sales and AMU in the animal sector in four Member States (36%), i.e. Bangladesh, Bhutan, Nepal and Sri Lanka (Phase 2). In Indonesia, surveillance of sales, distribution and use of antibiotics is limited, but surveys for antibiotic sales based on antibiotic import data and antibiotic production data are conducted (Phase 3). Thailand has set up national surveillance of the use and sale of antimicrobials in the veterinary sector, and the information is shared annually with the OIE, on the basis of sale estimates of antimicrobials in the veterinary sector (Phase 3). Indicator 7.3: Biosecurity (IPC) in the animal sector Three Member States (27%), i.e. Maldives, Myanmar and Timor- Leste, are beginning to explore and adopt measures to install national biosecurity practices in the animal sector (Phase I). Another three 2016 2018 1 1 1 0 0 0 0 5 3 6 4 0 1 0 0 1 2 3 4 5 6 7 National AMR containment policy and regualtions (animals) National surveilance for AMR & AMU (animals) Biosecurity in animal sector AMR awareness and education (animal sector) National AMR containment policy and regualtions for controlled release of AR & AMR (environment)* National surveillance of AR & AMR in wastewater* AMR awareness and education (environment sector)* N o of c ou nt rie s (> p ha se 3 ) Fig 11. Focus area 7: One Health engagement 23 Member States (27%), i.e. Bhutan, DPRK and Nepal, are establishing a programme, though there is no specific department that can assume the exclusive responsibility of biosecurity in the animal sector (Phase 2). Bhutan has developed standard operating procedures (SOPs) for government-manned farms, but there are no guidelines for small/ backyard farms so far. Also, the policy for vaccination in the animal sector is yet to be developed. A manual on biosecurity is available in Nepal and training sessions are conducted for farmers, as well as technicians, in the veterinary sector. Barring Bangladesh, none of the Member States were found to have a policy or regulatory framework that could help control the release of AR/AMR surveillance in waste water from antibiotic manufacturers/ homes (Phase 1). The DPRK has implemented biosecurity guidelines and established systems to monitor compliance, although the guidelines do not specifically address AMR. Both India and Sri Lanka have developed policies, guidelines and strategies for biosecurity in the animal sector, and are expanding these by scaling up activities nationwide (Phase 3). In India, training programmes and workshops are organized regularly to strengthen the implementation of biosecurity measures. The biosecurity manual is followed both by public and private sector farms, even though no guidelines for backyard poultry exist in India. The biosecurity audit process has been developed in India, but its implementation is limited. In Sri Lanka, vaccines such as the Salmonella vaccine are available free of charge for backyard poultry handlers. In addition, guidelines for outbreak response are in existence to support biosecurity in the animal sector. Following avian influenza outbreaks in the past, significant investments have been made in Indonesia to strengthen biosecurity in the animal sector, especially with technical and financial support from FAO and USAID. In Indonesia, biosecurity is fully operational in the animal sector (Phase 4) as guidelines, policy and training manuals have been developed and implemented with regular audit being conducted for large-scale farms. There has been an advancement of biosecurity in Thailand, with regular and sustained activities for IPC being conducted in the animal sector (Phase 5). There were various levels of success in different countries. Some had adopted measures to instal biosecurity practices in the animal sector and developed SoPs for government-manned farms, with guidelines for small/ backyard farms. Others had undertaken training to strengthen the implementation of biosecurity measures and conducted regular audits for farms. Indicator 7.4: Education on AMR in the animal sector and raising awareness It was observed that no strategies/ policies have been developed to initiate systematic efforts for comprehensive awareness of Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 24 AMR amongst professionals in the veterinary sector in six (55%) Member States, i.e. DPRK, India, Maldives, Myanmar, Nepal and Timor-Leste (Phase1). In Bangladesh, strategies to create awareness have been developed (but not implemented) to include training of health-care professionals in the animal sector (Phase 2). Bhutan, Indonesia and Sri Lanka (27%) have incorporated concepts related to AMR in continuing professional development programmes and developed specific programmes for awareness among veterinary professionals (Phase 3). Campaigns to generate awareness have been conducted using a multisectoral approach, along with revisions in the curriculum in veterinary sector in Thailand (Phase 4). Indicator 7.5: A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein Engagement and involvement of the environment sector has been found to be inadequate across the Region and most Member States are beginning to include the environment aspect to strengthen multidisciplinary participation under the One Health approach. Sri Lanka and Thailand have a national AMR containment policy and a regulatory framework to control the release of AR and AMR into the environment and management therein (Phase 2). All other Member States are still in the process of developing policies and regulations (Phase 1). In Sri Lanka, the national waste management policy has been drafted to include all regulations and guidelines, including waste water treatment by manufacturing units and hospitals. A central environment authority has been established for the implementation of the regulations and an environment impact assessment has been conducted. In Thailand, the existing policies address AMR in the environment and there are well-established standards of surface water testing and of waste water effluents from industries and the municipal wastewater system. Indicator 7.6: National surveillance of AR and AMR in waste water The release of resistance-driving chemicals into the environment is increasingly being recognized as a cause of the spread of clinically relevant antibiotic resistance. This has made it imperative to monitor and control the disposal of AR in the environment and to have a system of surveillance of AMR in wastewater from drug manufacturing units, institutions, homes and waste water plants. Thus, an additional indicator was added to the situation analysis tool in 2018. In Bangladesh, policies are in place for monitoring waste and waste water from antibiotic manufacturing units but these are yet to expanded to include specific indicators for assessing the quantum of antimicrobials in waste generated by human/animal use (both terrestrial and aquatic) (Phase 3). 25 Indicator 7.7: AMR awareness generation and education in the environmental sector An additional indicator to monitor the progress on AMR awareness generation in the environmental sector was included in the situational analysis tool . It was observed that no communication strategies have been developed in nine Member states (82%) (Phase 1) to generate comprehensive awareness on environmental safety in the AMR context. In Maldives, the national AMR containment policy addresses issues pertaining to awareness and education for the environment sector (Phase 2) In Thailand, a specific policy for waste management has been developed, primarily for the pharmaceutical sector. This was preceded by a core set of activities including the development of guidelines and standards and identification of resources for the implementation and monitoring of the programme (Phase 2). Focus area 8: Overarching coordination mechanisms for One Health engagement (Fig. 12) Addressing the rising threat of AMR requires a holistic and multisectoral (One Health) approach. To assess progress on One Health engagement, an additional subset of indicators was added to the situational analysis tool developed by the Regional Office. The phase of progress related to each indicator was reviewed by national stakeholders in close coordination with Tripartite experts during the workshop. Indicator 8.1: Overarching AMR coordination mechanism Apart from Timor-Leste and Indonesia, which do not have any formal multisectoral governance or coordination mechanism (Phase 1), all Member States have established multisectoral working groups. Six Member States have multisectoral working groups/coordination committees under government leadership (Phase 2). Bhutan has progressed to holding regular meetings, with defined reporting mechanisms for the multisectoral group (Phase 3). Bangladesh and Thailand have functional multisectoral committees with advanced objectives, including the development of restrictions on critically important antimicrobials (Phase 4). Indicator 8.2: Inclusion and engagement of all relevant sectors in the NAP-AMR In seven (64%) Member States, namely Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka, the NAP-AMR includes relevant sectors (Phase 2)." In both India and Timor Leste, NAP-AMR provides for the inclusion and engagement of relevant sectors to facilitate One Health engagement. In DPRK, there is an absence of multisectoral involvement due to the lack of awareness, but the issue is now beginning to draw attention (Phase 1). In Thailand, multisectoral coordination, with the inclusion and engagement of all the relevant sectors, has attained a phase of sustainable operation (Phase 5). Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 26 Indicator 8.3: A platform and/ or mechanism for sharing AMU monitoring data In seven Member States (64%), there is no formal platform or mechanism for the sharing of AMU monitoring data from all the relevant sectors (Phase 1). In Bhutan, there are defined reporting mechanisms for multisectoral groups that serve as platforms for the sharing of AMU monitoring data amongst the relevant sectors (Phase 2). In Sri Lanka and Thailand, a platform for the sharing of AMU data amongst the relevant sectors is clearly defined and functional (Phase 3). Bangladesh has a well-developed platform and mechanism for the sharing of AMU monitoring data (Phase 4). Indicator 8.4: A platform and/ or mechanism for sharing AMR surveillance data In seven Member States (64%), i.e. Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand, defined reporting mechanisms for multisectoral groups have been established and serve as a platform for sharing of AMR surveillance data amongst relevant sectors (Phase 2). The remaining four Member States (36%), Bhutan, DPRK, Maldives and Timor-Leste, do not have a formal mechanism for sharing of AMR surveillance data (Phase 1). Fig. 12. Focus area 8: Overarching coordination mechanisms for One Health engagement *New indicator introduced in situational analysis tool, 2018 0 0 0 0 0 0 3 3 3 0 7 2 0 1 2 3 4 5 6 7 8 Overarching coordination mechanism* Inclusion and engagement of relevant sectors* Platform for sharing AMU data* Platform for sharing AMR data* Nationally coordinated AAW* Co-sharing of resources for AMR initiatives* N o of c ou nt rie s (> p ha se 3 ) 2016 2018 27 feedback, monitoring and evaluation (Phase 5). Indicator 8.6: Mechanisms for co-sharing of resources for AMR initiatives exist The mechanisms for co-sharing of resources for AMR initiatives are still being discussed and explored in eight Member States (73%) (Phase 1). After establishing the initial core set of activities, Maldives is beginning to instal co-sharing of resources for AMR initiatives amongst various stakeholders (Phase 3). In Sri Lanka, activities for co-sharing of resources for AMR initiatives have been undertaken and are at the stage of initial implementation (Phase 3). Indicator 8.5: AAW is nationally coordinated and celebrated with involvement and contributions from all relevant sectors exists Antibiotic Awareness Week (AAW) is nationally coordinated and celebrated, with the involvement of and contributions from all relevant sectors in five Member States (45%), i.e. Bhutan, Maldives, Nepal, Thailand and Timor-Leste (Phase 3). DPRK, India and Indonesia are yet to establish multisectoral coordination amongst all relevant sectors for AAW (Phase1). In Bangladesh, involvement of and contribution from all sectors are fully operational (Phase 4). In Myanmar and Thailand, nationally coordinated AAW celebrations are in an advanced stage, with regular Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 28 Inspite of the fact that the SEA Region has been identified as the region with the highest potential burden of AMR, it has not gained significant traction in policy and/or programmatic areas. As a result, systemic responses to AMR as a public health issue have been largely neglected. However, the announcement of the GAP- AMR in 2015, followed by a series of advocacy initiatives at the global and regional levels, especially by WHO and the other Tripartite partners, has brought the issue to the forefront in the Region. The 2015 GAP-AMR called for the development of comprehensive NAP-AMRs aligned with its strategic objectives and implemented using the One Health approach. As the first step in the implementation of the AMR prevention and containment efforts in the Region, a situational analysis of AMR containment efforts was initiated by the WHO Regional Office in 2016. The findings of the situational analaysis were incorporated in a roadmap for AMR prevention and containment in the Region. These publications subsequently formed the basis for the development of most of the NAP- AMRs in the Member States. By mid-2017, all 11 Members States had prepared their NAPs and initiated programmes based on them. The follow-up inter-country meetings in 2018 helped assess progress and identify gaps and challenges in implementation and made actionable recommendations. Overall, the discussions pointed towards significant progress in AMR prevention and containment initiatives in the Region in the last two years. The progress made in initiating the programmes was confirmed by the change in median progress between 2016 and 2018, notably in terms of ongoing advocacy and political commitment. It emerged that interventions aligned with existing efforts, such as sanitation and hygiene programmes, demonstrated better results. Also, spreading awareness, imparting education/training and fostering collaboration across sectors during AAWs were easier and quicker, even though the quality, extent and robustness of these initiatives was yet to be established through systematic monitoring and evaluation. Enabling regulatory frameworks, that are suitably adapted to the needs of AMR, are essential to Conclusions The 2018 situational analysis highlighted the continuing challenges that need to be addressed as a priority by the Member States and the technical agencies that support implementation of their NAP-AMR. Going forward, the momentum that has been generated will be sustained only if there is multisectoral collaboration, including the establishment/ availability of platforms that enable joint planning, exchange of surveillance information and sharing of resources. 29 containment efforts. The SEA Region has traditionally responded to public health issues, especially those dealing with use of medicines/ medicinal products, with regulation heavy responses. So, not surprisingly, the progress made in implementing NAPs in the last two years, again indicates focus on regulations in the context of AMR and AMU (regulation of antibiotics and APIs and OTC sales). However, in most cases, implementation posed challenges and what will be required is effective operational plans that will help overcome these implementation challenges. Investments have been made over the years to strengthen public health laboratories in disease surveillance and these have provided an important launch pad for initiating a laboratory network in most countries. Finally, progress has been made in establishing governance mechanisms as part of the NAP-AMRs, forming the basis for future advancement and consolidation of multisectoral and collaborative action. Qualitative differences were seen in the level of success achieved by the Member States, with a few recording higher levels of implementation over the two years between analyses (Phase 4 and above). This provided an opportunity for learning from experiences within the Region. While Thailand made progress across all focus areas and indicators, the strategic research agenda developed by it is emerged as a good practice model. Sri Lanka paid attention to their environmental sector making it a key stakeholder in AMR containment. Further, it stood firm on making its public health system stronger, resulting in improved sanitation/ hygiene, vaccination and effective implementation of regulations. Effective multisectoral coordination (One Health) was well exemplified in Bangladesh, and so is it’s more modern pharmacy regulation system. India stood out for its robust regulatory frameworks as well as community awareness initiatives in the area of sanitation by launching a massive cleanliness mission across the country fixing accountabilities and involving multiple layers of society. Stewardship was successfully implemented in Bhutan as were high intersectoral coordination and strong political will. Further, these were characterised by well-defined policies/guidelines, regulatory systems and budgetary provisions for AMR containment efforts. Indonesia did a fine job in consolidating its regulatory frameworks and a robust biosecurity system for the animal sector. It also succeeded in mobilizing the community by creating awareness on the smart use of medicines. Infection prevention and control in support of AMR containment through sanitation/ hygiene interventions and vaccination proved to be a major strength in DPRK, Myanmar and Timor-Leste. DPRK carried out a nationwide coverage of safe water and sanitation and hygiene, while Myanmar put together systematic efforts in the area of capacity building of professional and paraprofessionals in addition to enforcing strong pharma related regulations. Good results were seen thanks to strong multisectoral coordination and synergy at the inter and intra departmental level. Nepal’s introduction of vaccination and good coverage ensured effective infection prevention. In Thailand, a strong and quality assured laboratory network and strong set of regulations provided Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 30 a deterrent to any kind of misuse. although OTC antibiotics can still be available in some locations. Strong political will and commitment were seen in Timor-Leste where greater government ownership translated into systematic and regular launch of awareness campaigns targeting different community groups. In general, there has been less progress across different focus areas and indicators in the animal health sector. This could impact One Health engagement and effective multisectoral collaboration. The limited systemic capacity of the animal health sector, typical of the Region, and a lack of resources could explain some of these gaps in progress. The environmental sector, in particular, is less integrated across all focus areas and indicators. This is probably a reflection of the lack of clarity in the collaborative frameworks that necessitate its involvement. Limited conclusive evidence on the role of the environment in the emergence and spread of AMR could also be a reason for weaker advocacy. The newly introduced focus areas with respect to overarching collaborative mechanisms brought out some of these gaps. The situation analysis revealed that in a majority of the countries in the Region, the implementation of AMR surveillance has not been initiated so far. While this is true of the human health sector, it is even more so in the animal and environment sectors. Other areas of concern are IPC in health-care facilities, HAI surveillance and AMSP, in which most of the countries in the Region have failed to reach initial implementation in the last two years. An in-depth analysis revealed lack of awareness, policies, standards and guidelines, which lead to the inability to highlight the relevance of these issues in the resource-constrained SEA Region. In addition, there is a lack of political will to support these important functions. WHO GLASS and other Tripartite partners would need to support surveillance, with technical backing and guidelines, on priority. None of the countries has taken steps towards the initial implementation of early warning systems. Globally, this critical function for AMR surveillance, containment and spread has suffered due to a lack of clarity on goals and standards. Recent efforts by WHO should help provide more clarity in this regard. The GAP-AMR has identified research and innovation as a key strategic objective so that evidence can be generated to guide current and future containment efforts. However, as has been demonstrated in many areas of public health, health research is often disconnected with the needs of policymakers and programme managers. Most countries in the Region are yet to put together a strategic research agenda that is relevant to the current policies and programmes and address implementation challenges in the way of AMR containment efforts in the Region. The discussions clearly pointed towards the need for greater clarity on research strategies. The research agenda proposed and being pursued by Thailand provides a good template for research priorities that are in line with the local needs and ensure a strong One Health collaborative focus. 31 The roadmap proposed by the Regional Office in 2016 provides clear guidance on the steps and initiatives that the Member States need to take to achieve sustainable programmes for AMR containment. Depending on their respective readiness and existing capacities, they can set their own agenda and pace, with a common vision and understanding of the good practices that need to be achieved as a result of different initiatives outlined in their NAP- AMR. Having strong operational plans with inbuilt monitoring and evaluation would be critical in ensuring progress and a degree of coherence in this complex multisectoral and multistakeholder issue. On the basis of the present situation analysis, 2018, the intercountry meetings identified country-specific recommendations (See Section on Country Profiles). Key recommendations to address main challenges of AMR containment in the Region Strengthen governance and multisectoral collaboration: Given its global health implications, AMR must be kept high on the agenda of policy-makers. There continues to be a need to strengthen governance and multisectoral collaboration in all Member States, with a special focus on non-human sectors. At the same time, the Member States must learn from each other’s experience and good practices from other Regions. The following measures must be taken. • Strengthen policy frameworks to provide an enabling environment to make AMR a priority public health issue. Place special focus on dedicated funding for AMR containment, especially from national sources when global momentum has settled. • Map the resources available in the Member States, develop operational plans and establish mechanisms for co-sharing resources for AMR initiatives. • Integrate monitoring and evaluation in the implementation plans as the programme and AMR interventions get scaled up, since it is important to calibrate response and keep pace with global developments and needs. Expand awareness of AMR and related issues: While this has turned out to be a low-hanging fruit for Member States in the Region, as demonstrated by the rapid scale- up of initiatives for generating awareness, their quality and impact are yet to be assessed. There have been similar challenges when dealing with the general public, farmers and professional groups. In order to ensure that programmes for raising awareness have the desired Way forward and recommendations Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 32 impact and are able to promote the prudent use of antibiotics in society as a whole, the following priorities must be set for the Region. • Continue efforts to increase awareness of AMR and related issues among different target groups, focusing specially on non-human sectors, to ensure their buy-in and commitment. • Develop and implement a comprehensive strategy to raise awareness amongst the public and professionals involved in the human, animal and environmental health sectors. • Promote the prudent use of antimicrobials among professionals of different sectors by enhancing the focus on AMR in the curriculum and training for continuous professional development courses. • Adopt a multisectoral approach by involving the marine, agricultural and environment sectors in generating awareness of the efficient management of waste water in the context of AMR. • Public and professional awareness (and knowledge, attitude and practice) should be assessed on a regular basis to guage the level of understanding the impact of awareness-raisng activities (response - behaviour change) and the successful/ unsuccessful fatures of awareness campaigns. Step up AMR surveillance across sectors: AMR surveillance needs to be strengthened. Besides, the availability of national guidelines that are aligned to international standards must be ensured. Surveillance should be bolstered by taking definite steps that include the following. • Introduce information management systems using information technology to improve the efficiency of surveillance systems. • Ensure the availability of trained human resources and infrastructure while focusing on quality assurance to attain the highest performance standards in laboratory-supported AMR surveillance across sectors. • Enhance the molecular detection capacity of the laboratory network, and explore the use of advanced software for data analysis and alert generation to set up EWS. Standardize and implement IPC and antimicrobial stewardship programmes: IPC and AMSP are cirtical interventions to reduce the use and prevent the emergence of AMR. In addition to ensuring that national guidelines are available, the following measures should be taken. • Integrate AMSP, IPC and surveillance of hospital-acquired infections in health-care facilities by ensuring high standards of service delivery. 33 • Strengthen the implementation of WASH practices nationwide and enhance the involvement of NGOs and local opinion leaders to build awareness and promote infection control measures in the community. Ensure rational use of antimicrobials and surveillance of use/sale: The use and sale of AMA have been traditionally supported through enabling regulations in the countries of the Region. However, these frameworks need to be suitably adapted so as to respond to the emerging needs related to AMR. Some of the priorities for the Region should be as follows. • Build the NRA’s capacity to review dossiers and registration of antibiotics; conduct post-market surveys for quality assurance of the antibiotics available; and implement regulations on finished products and APIs. • See to it that the organizational structure and capacity of the NRA is able to regulate pharmacies to meet the requirements of NAP. Increase the NRA’s capacity to monitor the consumption and use of antibiotics in humans through online sales, etc. • Promote regulatory cooperation in the SEARN on AMR for the import of medical products (medicines, devices and diagnostics) and laboratory network. Support implementation with standards and guidelines: In addition to strengthening regulatory capacity and frameworks, special focus is required for strengthening capacity for the implementation of various interventions and programmes. Two important intial steps would, therefore, be as follows. • Develop and implement standards and guidelines to support the implementation of the programme and ensure the quality of response. • Work on strengthening the priority areas for the Region, i.e. surveillance; IPC, including HAI; and AMSP. Make implementation research more acceptable and innovative: It is imperative to recognize the wider interpretation of research and innovation in the context of the Region. While countries like India and Thailand can boast of significant R&D capacity with expertise in areas such as the development of newer molecules, vaccine candidates and diagnostic platforms, the priority for most countries in the Region clearly appears to be implementation research. The following steps are recommended in relation to implementation research. • Prioritise strategic research agendas that can strengthen AMR containment programme delivery. Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 34 • Include other priorties that have the potential to impact the assessment of AMR containment initiatives with a special focus on economic burden from evolving AMR. Drive One Health agenda with investments and engagement across sectors: Special efforts are needed to accelerate interventions in non-human sectors and building their capacities for a meaningful engagement in the multisectoral response. This is true in particular of the environment sector, which has so far remained on the margins. The following steps are recommended in this regard. • Invest in strengthening surveillance of AMR, AMU and AR and regulatory capacity across sectors, at national and regional levels. This will help check the import of plants, animals and antimicrobials that tend to cross unmanned international borders easily. • Generate necessary evidence and enable frameworks to support interventions as part of the effort to encourage implementation research. Way forward for WHO and its regional Triparte partners To facilitate the implementation of NAPs, WHO and its regional Tripartite partners formed a Regional Tripartite Coordination Team to coordinate integrated support to Member States in technical guidance, advocacy, monitoring and fund- raising. Concerted efforts have been made to reach out to UNEP and explore specific collaborations on the implementation of policies and regulatory frameworks governing the use of antimicrobial agents, and laboratory networks for the surveillance of resistance to and rational use of antimicrobials. These efforts cover all levels across diverse sectors, including human and animal health, agriculture, food safety and environment. As a flagship priority for the Region, the Regional Office will continue, with the help of the Tripartite partners, to support the implementation of the NAP-AMR in Member States. It will: • provide support through evidence-based technical guidance customized for each Member State; • collaborate and review implementation status and measure progress in each Member State using the situational analysis tool developed by the Regional Office; • document technical support to the Member States and seek opportunities to document proof of evidence for advocacy and fund-raising; • strengthen collaboration and sharing of information with partners and WHO collaborating centres; • identify and collaborate with Member States that are willing to undertake interventions within their NAPs and demonstrate measurable outcomes or impact; 35 • respond to Member States’ requests to update AMR-NAPs, especially to include One Health approaches and to enhance the animal, crop, aquaculture and environment dimensions of the AMR threat; • strengthen a One Health partnership with the regional offices of OIE and FAO to combat AMR. Intercountry meeting to review implementation of national action plans on AMR, Bangkok, Thailand, 23–25 July 2018 Bhutan, Democratic Peoples’ Republic of Korea, Maldives, Nepal, Sri Lanka and Timor-Leste, 25 – 27 July 2018: Bangladesh, India, Indonesia, Myanmar and Thailand 36 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Country profiles Bangladesh Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 2 3 The NAP is in line with the GAP- AMR, developed and approved at the ministerial and Secretariat level. There is a functional multisectoral AMR national steering committee and national technical committee, with defined terms of reference of various stakeholders. Enforce policies and regulations to support smooth implementation of NAP-AMR. Ensure inbuilt mechanism for monitoring and evaluation, along with adequate budgetary provisions in operational plans developed for various AMR containment activities. 2. Raising awareness 2.1 Awareness campaigns for the public 3 4 Nationwide government-led campaigns, targeting public and professionals, are conducted during the AAW. Awareness- raising activities are conducted primarily during the AAW and there is limited focus on the generation of awareness throughout the year. Promote collaboration among all relevant stakeholders to conduct nationwide campaigns for the generation of awareness of AMR among the population. 2.2 Education and training strategies for professionals 1 3 The specific topic of AMR is in the process of being introduced in pharmacists’/ medical curriculums. AMR training is conducted for health professionals. Develop specific communication strategies targeting behavioural change and make plans to evaluate the impact of activities for raising awareness. Bangladesh should consider revising the medical and veterinary curriculums to focus on AMR issues. Design and implement specific courses for continuous professional development of health experts both in the human and animal sector. 37 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3. National AMR surveillance system 3.1 National human AMR surveillance 2 3 National guidelines and SOPs for human AMR surveillance have been prepared. National human AMR surveillance is in place and there are plans to expand the network nationwide. Data collection and regular training are conducted to strengthen surveillance. For further expansion and nationwide adoption of human AMR surveillance, it is essential to develop an accountability framework with a reporting mechanism, and ensure the availability of adequate funds for AMR activities across various sectors. 3.2 Strengthening of national laboratory network 2 3 The national reference laboratory follows the CLSI as a reference standard and supports the laboratory network. Conventional microbiological methods are followed in laboratory diagnostics and the laboratory network; molecular methods are yet to be adopted. National external quality assurance has not been established. Focus on capacity-building for laboratory diagnostics and ensure the availability of infrastructure and adequate reagents. Standardize laboratory surveillance by establishing national external quality assurance mechanisms. 3.3 Early warning systems 1 1 No EWS has been established for AMR bacteria. Plan to establish an EWS and consider developing the molecular detection capacity of the laboratory network supporting AMR surveillance. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 1 2 An AMSP has been planned and is under development. Develop comprehensive AMSP guidelines, covering training material and tools to monitor antimicrobial use in the human health sector. 4.2 NRA/ DRA 3 4 The NRA is fully functional and a national drug policy is in place. Promote regulatory cooperation on AMR in SEARN for the import of medical products, and quality assurance of the laboratory network. Develop an API analysis system. 38 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 4.3 Surveillance of antimicrobial use and sale among humans 2 3 Guidelines have been developed to survey AMU in humans. Antimicrobial manufacturing data is collected under regular monitoring by the DRA. Develop a national AMR containment policy and establish an AMU monitoring system to control AMU in humans. Expedite the completion of the antimicrobial consumption survey and develop operational plans to monitor the use and sale of antimicrobials in the human health sector. 4.4 Regulation of finished antibiotic products and APIs 3 4 The NRA is fully functional and inspection is carried out, but the capacity for the enforcement of the regulations is limited. Provide adequate human and financial resources to strengthen the regulatory capacity of the NRA to conduct pre- and post- marketing surveillance, and enforce regulations on finished products and APIs to support GMP. 4.5 Regulation of pharmacies regarding OTC sale and inappropriate sale of antibiotics and APIs 3 4 A model pharmacy regulation system is in place and document list of drugs for OTC sale. The national drug policy provides for sale of antimicrobials on prescription only; however, there is limited capacity for the enforcement of regulation. To regulate inappropriate sale of antibiotics and APIs, consider advanced IT solutions to manage referral, prescription and the drug-dispensing system. 5. Infection prevention and control and AMR stewardship programme 5.1 AMSP in health- care setting 2 2 There is a national IPC/ AMR operational plan, but implementation is limited for want of SOPs, guidelines and protocols, and laboratory capacity for antimicrobial sensitivity testing. Develop coherence and an integrated AMSP, IPC and surveillance of HAI. 5.2 IPC programme in health-care setting 2 2 There is a national infection control committee and national IPC guidelines are under development. Develop policy and guidelines for AMSP and strengthen the laboratory capacity for AMR/AMU surveillance in the human health sector. 5.3 National HAI and related AMR surveillance 2 2 HAI surveillance has been initiated in a few public and private facilities. Develop policy/guidelines and build capacity for HAI. Expand this across the country in a step-wise manner. 39 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5.4 Sanitation and hygiene 1 4 There is a national campaign to improve sanitation and hygiene in communities through the WASH programme. Data on access to safely managed water are available. To strengthen sanitation and hygiene activities, focus should be placed on expanding the implementation of the WASH programme. 5.5 Vaccination NA 4 PCV and haemeophilus influenza B (HiB) vaccine are included in the expanded programme of EPI. Typhoid vaccine is not. The national indicators for vaccine coverage are good. The Member States should consider developing a vaccination policy in the context of AMR prevalence and practices. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 2 2 Policies have been framed and there are plans to foster research and innovation on AMR. Encourage R&D and innovation for generation of evidence to support the effective implementation of NAP-AMR. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animals 2 4 The national drug policy addresses AMR and a legal framework prohibits the use of antimicrobials in animal feed. Regulatory frameworks have been implemented with some monitoring but the capacity for enforcement is limited. Develop an AMR containment policy and tools to implement and monitor AMR containment in the animal sector. Ensure that there are adequate funds for AMR containment in the veterinary sector. 7.2 National surveillance of AMR, and use and sales of antimicrobials in the veterinary sector 2 AMU-2 AMR-2 Guidelines have been developed to survey antimicrobial use in the human and animal sectors. The capacity for surveillance of AMU and AMR is limited. Develop operational plans for antimicrobial use and sales in the animal sector. Strengthen the inspection system for monitoring the implementation of the AMR containment policy in the animal sector. 7.3 Biosecurity (IPC) in the animal sector 2 3 Biosecurity measures have been initiated in the poultry sector following bird flu outbreaks. Develop guidelines to support biosecurity measures in other animal sectors; and enhance awareness in and diagnostic support for the veterinary sector. 7.4 AMR awareness generation and education in the animal sector 2 2 Strategies have been formulated to raise awareness among veterinary professionals. Experts from the human and animal sectors are involved in training health-care professionals. Formulate strategies targeting different groups engaged in animal handling, with an emphasis on behavioural change for prudent AMU in animals. 40 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 Under the National Regulations, policies are in place for monitoring waste/waste water from antibiotic manufacturers. It is mandatory to process waste before releasing it into the environment. Effluent treatment plants are compulsory and expired antimicrobials are destroyed by incineration. However, there is no specific policy aimed at reducing AR and AMR in environment. There is a need to expand policies, have an operational plan including monitoring and evaluation (M&E) system to assess AMR and AR load in waste and waste water generated by all relevant sectors. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 3 Policies are in place for monitoring waste and waste water from antibiotic manufacture under the National Regulatory of Drugs. Need to expand policies, operational plan including M&E system to all relevant sectors such as human, animal and fisheries. Develop national policy directed at reduction of AR and AMR waste generation supported by operation plans to assess AR/ antimicrobial load in waste and wastewater from relevant sectors. 7.7 AMR awareness generation and education in the environmental sector NA 1 There is no policy/ strategy on AMR in waste to ensure environmental safety. The NRA policies focus on the safe disposal of waste from manufacture. Guidelines are in place for the management of hospital waste. Develop a communication strategy for awareness generation and education in the environmental sector. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism NA 4 There is a multisectoral national steering committee as well as a national technical committee on AMR, led by the MoH, with defined terms of reference (ToR) for various stakeholders. Strengthen the existing coordination mechanism between all relevant sectors, with enhanced engagement and involvement of the environment, food safety, education, aquaculture, and animal and human health sectors. Include and engage all relevant sectors in NAP-AMR. 41 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.2 Inclusion and engagement of all relevant sectors in the NAP-AMR NA 2 The NAP-AMR engages human health, animal health, drug administration for humans and animals, plant health, civil society, and the private sector (primarily pharmaceutical and chemists’ associations), and WASH. No specific recommendation 8.3 A platform and/ or mechanism for sharing AMU monitoring data from all relevant sectors NA 4 The NRA monitors AMU in the human and animal sectors. A multisectoral expert committee is leading a survey on antimicrobial consumption. Establish coordinated mechanisms for AMR/AMU surveillance and ensure the implementation of AMR containment across the relevant sectors. 8.4 A platform and/ or mechanism for sharing AMR surveillance data from all relevant sectors NA 2 An interministerial secretariat for One Health is in place, but there is a need to strengthen the involvement of various stakeholders.Though there is an AMR surveillance mechanism for the human sector, there is none for the animal sector. The food safety surveillance system is functional. Provide a platform for sharing monitoring data regularly with national and international stakeholders across all sectors to ensure evidence-based policy decisions. 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 4 AAW is celebrated annually with multisectoral participation, including scientific seminars targeting experts from various sectors. Campaigns are organized regularly for awareness generation among pharmacists supporting the human and animal sectors. Conduct an assessment of the impact of awareness generation activities, with the involvement of and contributions from all relevant sectors. Promote active participation of various sectors to ensure that AAW is nationally coordinated and celebrated. 8.6 A mechanism for the co-sharing of resources for AMR initiatives NA 1 Trainings organized by the health sector for capacity- building of experts from various sectors and awareness building activities, funded by MoH, for all stakeholders are some initiatives under the mechanism of co- sharing resources. To identify resources and establish a mechanism for the co-sharing of resources for AMR initiatives. 42 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance 2016 2018 Fig 13: The figure shows an average of phase-grading for all indicators Good practice The modern pharmacy regulation system established by the country has been identified as a good practice in the Region. Under this system, a comprehensive list of drugs for OTC sale is regulated under the national drug policy that provides for the sale of antimicrobials only on prescription. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 43 Bhutan Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 3 3 A comprehensive NAP for 2018– 2023, in line with GAP-AMR, was launched during November 2017. Budgetary provisions have been made for AMR activities in the 12th Five-year Plan (FYP). Continue to maintain strong political will and commitment to support AMR activities. There should be adequate budgetary provisions in the FYP. Build further on ownership of AMR implementation by regulatory authorities. 2. Raising awareness 2.1 Awareness campaigns for the public 3 4 Nationwide awareness week is observed, with television campaigns, talk shows, animation and pamphlets, to enhance the awareness of AMR among the general public at large. Consider developing a strategic plan to evaluate antibiotic literacy and behaviour among the public through a baseline survey, followed by a targeted campaign to enhance awareness. 2.2 Education and training strategies for professionals 2 3 The inclusion of AMR-related issues in induction training for health professionals and in modules on the rational use of drugs are strategies implemented for awareness of AMR. Efforts are ongoing to modify the medical curriculum by incorporating details on AMR/ AMS. Take measures to revise and update all health professional curriculums with a focus on AMR/ AMS; also include guidance on competency evaluation. 3. National AMR surveillance system 3.1 National human AMR surveillance 2 2 Guidelines have been prepared but implementation is limited due to the scarcity of skilled manpower, funds and capacity for data management. To understand the impact of AMR on the population and monitor trends in AMR, it is crucial to set up systems for linking microbiological and epidemiological findings. The Member States should consider using systems such as WHONET for robust data collection and analysis. There is a need to streamline data-sharing modalities to ensure regular and timely availability of all information with policy-makers. 44 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 3.2 Strengthening of national laboratory network 3 3 The national AMR reference laboratory is functional, with a quality-assured laboratory network at a few centres, and selected sites are participating in EQAS. The CLSI for standardized microbiological laboratory procedures are being followed. GLASS enrolment is under progress. To maintain the highest standards in laboratory procedures, the Member States should focus on capacity-building of laboratory staff and data-handling experts. 3.3 Early warning systems 2 1 Efforts are ongoing to establish EWS, prepare a list of priority AMR bacteria and verify identified AMR organisms at the earliest. There is a need for expertise to develop EWS and verify identified AMR organisms at the earliest. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 2 2 An AMSP has been established only at the national hospital and its expansion to other AMR/AMU sentinel sites is limited due to the scarcity of trained human resources. There is a need to expedite the finalization of the existing AMSP national antibiotic policy and ensure that M&E tools are included in the AMSP guidelines. There is a need to expedite the finalization of the existing AMSP national antibiotic policy and ensure that M&E tools are included in the AMSP guidelines. 4.2 NRA/ DRA 5 4 Tools for quality assurance & registration of antibiotics is in place along with post marketing surveillance to monitor sale and distribution of antibiotics. However, there remains limited capacity for enforcement of policies and regulation Promote regulatory cooperation in South East Asia Regional Network (SEARN) in AMR for importing medical products and ensuring regulatory cooperation in labs. Strengthen regulatory registration capacity of NRA to register, undertake post marketing surveillance and testing of antimicrobials. 4.3 Surveillance of antimicrobial use and sale among humans 1 2 National policy or plan on surveillance of use of antimicrobials have been developed and approved but are yet to be fully implemented. PPS in few hospitals are conducted twice a year to capture the seasonal variations. Develop NRA capacity through data analysis for monitoring antibiotic consumption and use 45 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 4.4 Regulation of finished antibiotic products and APIs 4 4 Regulatory authority and systems of regulation on import, manufacture, sale and distribution of antibiotics is in place and inspection is implemented . However, capacity for enforcement of policies and regulation is limited by and inspection coverage restricted due to resource constraints Develop regulatory cooperation through SEARN for access to quality products and boost capacity building of NRA along with advocacy to implement regulation for dossier evaluation in antibiotic products and GMP inspection 4.5 Regulation of pharmacies regarding OTC sale and inappropriate sale of antibiotics and APIs 5 5 System for regulating sale and distribution of antibiotics from pharmacies is in place and inspection is fully implemented. This however does not completely stop illegal entry of medicines through porous borders Capacity building for NRA to be stepped up besides providing adequate human and financial resources for control of sale of antibiotics including e-pharmacies 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 2 2 Strong regulatory frameworks are being established and plans are in the offing to establish in referral hospitals. Antibiotics are prescribed only by physicians with reserved antibiotics having limited access; national essential medicine list available. Training / sensitization of physicians is being done and awareness in public domain stepped up. However, porous borders allow ready availability of antibiotics Stronger regulation needed for drugs brought across the border by members of the public. This should be backed by ongoing awareness programmes and activities 5.2 IPC programme in health-care setting 3 2 IPC programme and capacity plans implemented and a National IPC committee in place. Monitoring and reporting formats are being used and guidelines on waste management shared. WASH assessment in health facilities has also been done on priority basis. Training and certification for dedicated ICNs to be done in a uniform manner along with regular IPC audits. Feedback from IPC professionals must feed into hospital/health-care facility designs and results from KAP studies on hand hygiene etc to help refine existing protocols. 46 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 5.3 National HAI and related AMR surveillance 4 2 HAI surveillance (for pneumonias, UTIs and blood stream infections) including point prevalence surveys conducted in select national and regional hospitals, but is not fully standardised and data too is not analyzed completely. Meanwhile, the vital role of IPC is emphasised with every HCF (IC Nurse) encouraged to report monthly in real time according to defined criteria. Dedicated, trained/ certified IPC nurses are the need of the hour. Lab capacity strengthening must continue and data analysis evaluated from time to time. 5.4 Sanitation and hygiene 5 5 HCF have programmes for WASH and waste disposal fully implemented nationwide, but not specifically in the context of AMR. Monitoring of water quality is undertaken, but can be strengthened further 5.5 Vaccination NA 1 Vaccine coverage is 96% in general population. And PCV 13 launched, but plan is to implement it in 2019 Impact must be measured on several counts 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 2 2 NAP has provisions for R&D, but there is limited financial resource allocation. There is a strong need for research work to be more structured and targeted to benefit the overall implementation of NAP. Full targeted research proposals on baseline data on AMR and AMU and other proposals related to AMR should be prepared to support implementation of NAP, while seeking funding support from and collaboration with other institutes for such research proposals. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animals 2 3 The Medicine Act of Bhutan, 2003 and Bhutan Medicines Rules and Regulation, 2012 require that all medicines, including antimicrobials which are imported into the country, are registered with DRA/NRA. It also classifies all antimicrobials as prescription-only drugs. Regulatory enforcement is in place and is carried out by the regulatory authority. Thus initial implementation policies and regulatory frameworks have been implemented, but there is limited capacity for monitoring registration and AMU. Assess status of AMR surveillance system in animal sector and develop structured national AMR surveillance plan for the sector, with a focus on coordinated policy on usage of critical antibiotics among both humans and animals. Develop specific training programmes for para- professionals on AMU and AMR. 47 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 7.2 National surveillance of AMR, and use and sale of antimicrobials in veterinary sector 1 AMU-2 AMR-2 Limited information is available on the use and sale of antimicrobials at the national level in the veterinary sector. According to the national policy, information on the use of antimicrobials in the veterinary sector has been annually contributed to the OIE database since 2015. Assess the status of the AMR surveillance system in the animal sector, develop a structured national AMSP for the animal sector, with a focus on coordinated policy on the use of critical antibiotics, both among humans and animals. Develop specific training programmes for para-professionals on AMU and AMR. 7.3 Biosecurity (IPC) in animal sector 2 2 Biosecurity policies, guidelines and strategies have been developed, but these are more generic and do not cover all aspects of IPC in animal sector. Reinforce biosecurity policies, guidelines and strategies. Follow this with training of individuals handling animals in the private and government sectors. Consider establishing/ assigning clear responsibility to biosecurity department. 7.4 AMR awareness generation and education in animal sector 2 3 Guidelines for the use of antibiotics in livestock were developed in 2017. A national consultative and awareness workshop on AMR for livestock was conducted. The College of Natural Resources is the apex centre for training para- professionals who support veterinarians in animal sector activities. Develop specific training programmes for para- professionals on AMU and AMR. There is a need to develop messages and channels of delivery for the generation of awareness, specifically amongst farmers. 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 There is no specific policy to control the release of AR and AMR into the environment. The existing guidelines for waste water and waste disposal do not specify indicators for assessing quantum of disposed pharmaceuticals in waste generated by human/animal use. Develop policies and targeted strategies on AMR in waste to ensure the safe disposal of pharmaceuticals in the environment. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1 Guidelines for waste water and waste disposal do not specify indicators for assessing the quantum of disposed pharmaceuticals in waste generated by human/animal use. Also, there is no specific policy to control release of AR and AMR into the environment. Develop policies and targeted strategies on AMR in waste to ensure the safe disposal of pharmaceuticals in the environment. 48 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 7.7 AMR awareness generation and education in environmental sector NA 1 There is a need to recognize the importance of the environment sector by framing policies or targeted communication strategies to ensure the safe disposal of pharmaceuticals in the environment. Foster the inclusion of the environment sector in the implementation of NAP and involve the environment sector in the AMR network. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 3 An Inter-Ministerial One Health committee (IMCO) has been set up, but it is yet to be fully operationalized. The AMR technical committee has two subcommittees – one each for animal and human health. Both report to IMCO. Detailed ToR of the technical AMR committee are to be developed. To ensure smooth implementation of AMR activities, build synergies and further strengthen intersectoral coordination. 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 2 The health sector leads the work on AMR in accordance with NAP and engages other sectors, such as agriculture, wildlife, plant life and education. The involvement of environment, food and other relevant sectors is under consideration. To ensure smooth implementation of AMR activities, build synergies and further strengthen intersectoral coordination. 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 2 AMU monitoring data is informally exchanged between the human health and animal health sectors during technical committee meetings conducted quarterly. The animal health sector data, based on procurement information, is submitted annually to the OIE. No data specific to AMR in animal health is currently available. Develop integrated monitoring and surveillance mechanisms for antimicrobial surveillance, as well as use and sale of antimicrobials in human, animal and plant sector. 8.4 A platform and/ or mechanism for sharing of AMR surveillance data from all relevant sectors NA 1 AMR surveillance data is generated for human health, but not systematically shared with other relevant sectors. There is no AMR surveillance data from the animal sector. Develop integrated monitoring and surveillance mechanisms for antimicrobial surveillance, as well as use and sales of antimicrobials in human, animal and plant sector. 49 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance 2016 2018 Fig. 14: Situational analysis of progress in AMR prevention and containment in Bhutan, 2016–2018 Good practice The high-level intersectoral coordination between the agriculture, human and animal health sectors is impressive. The performance statdards of the laboratory network to support AMR surveillance in the veterinary sector are high. A strong political will and commitment to reverse AMR trends is evident from the well-defined policy guidelines, ownership by regulatory authorities and adequate budgetary provisions to support AMR implementation. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 8.5 AAW is nationally coordinated and celebrated with involvement of and contribution from all relevant sectors NA 3 The AAW is nationally coordinated by the health sector and has been celebrated annually with the involvement of the agriculture sector since 2016. Build ownership and strengthen coordination amongst various stakeholders during AAW celebrations. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 1 There is an informal system of resource-sharing for AMR initiatives, such as jointly conducting laboratory training both for human and animal health. However, there is no documented agreement on co- sharing of resources available. Member States should identify the resources available and develop operational plans and establish a mechanism for co-sharing of resources for AMR initiatives. 50 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 DPRK Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue NA 3 The NAPis in line with GAP-AMR and has been developed with defined activities. A national multisectoral committee on AMR has been established. Budgetary provisions have been made but lack dedicated fund allotment. Enhance engagement and involvement of all relevant sectors and ensure that the NAP-AMR is endorsed by all concerned ministries. To operationalize the AMR coordination committee with a multisectoral approach, it is essential to develop an accountability framework with a reporting mechanism and ensure sustainable funds. 2. Raising awareness 2.1 Awareness campaigns for the public NA 3 National-level awareness campaigns have been launched, using locally developed materials. Advocacy for AMR containment with high-level policy-makers is the need of the hour to enhance political will and commitment. It is recommended that communication strategies for the public be developed on the lines of the latest global information and internationally available standardized IEC material be translated into the local language. 2.2 Education and training strategies for professionals NA 2 Plans for professional training have been developed and training courses for health-care workers are conducted annually. Develop awareness programmes, trainings and workshops, on the basis of the latest global information on AMR, for individuals engaged in human health, food safety, agriculture, environment and other relevant sectors. 3. National AMR surveillance system 3.1 National human AMR surveillance NA 2 National guidelines have been developed for AMR surveillance in the human sector, but these are not aligned with international standards. Data analysis from ongoing AMR surveillance needs to be strengthened. Strengthen the national guidelines for AMR surveillance in accordance with international standards. Encourage the use of the software WHONET for efficient data management and analysis. 51 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3.2 Strengthening of national laboratory network NA 1 A national reference laboratory has been established, but it is not in line with international standards and lacks guidelines for antimicrobial sensitivity testing. AMR surveillance with limited quality control measures is operational at a few health- care facilities. To support human AMR surveillance, establish a national laboratory network, introduce and adapt international standards and guidelines, focus on capacity- building of laboratory staff and develop quality control systems with EQA. 3.3 Early warning systems NA 1 There is no EWS. Develop plans to establish an EWS for emerging resistance on a national scale. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship NA 2 The national AMSP policy is to be finalized and the essential medicine list needs to be revised. Organize stewardship activities into a comprehensive AMSP. Develop standard treatment guidelines for the use of antibiotics with technical support from WHO and consider adapting the AWARE framework to refine and revise the essential medicine list. Improve access to and availability of drugs nationwide. 4.2 NRA/DRA NA 3 NRA is existing and operational Develop regulatory cooperation in SEA regulatory network for AMR and strengthen national medical products quality assurance of antibiotics through SEARN 4.3 Surveillance of antimicrobial use and sale among humans NA 3 Estimation of needs has been carried out at facility level as part of national drug management system although no data has been collected so far on sales and consumption at national level due to lack of technical capacity and standard guidelines for surveillance of AMU Develop and adapt WHO standard Guidelines and capacities on analysis of antibiotic sales/ consumption data and production of annual reports. There is a suggestion that WHO could support capacity building in developing standard tools 4.4 Regulation of antibiotic products and APIs NA 3 NRA regulates all aspects of antibiotic manufacture, import, storage and sales despite lack of capacity including human and physical resources Capacity building must be strengthened to implementNRA functions. Also greater access to the SEA regulatory network for technical support and cooperation would go a long way in improving the overall national system 52 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 4.5 Regulation of pharmacies regarding OTC and inappropriate sale of antibiotics and APIs NA 1 Government supplies drugs to facilities and pharmacies; drugs are centrally procured. All facilities and pharmacies are government owned, hence ensures quality. However, sale of drugs without prescription remains a challenge Enable availability and effective prescription guidelines for antibiotics in public sector by developing regulations and guidelines for monitoring OTC sales and establishing a system for analysing data on sales 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting NA 2 There is no AMR stewardship programme in HCS though guidelines are available in health facilities for prescribing medicines. Only doctors can prescribe them and they are all trained in clinical management guidelines. Decision for use of antibiotic use is based on antibiotic susceptibility test at provincial hospitals. More sophisticated antibiotics are available at higher level facilities and prevention of infections in HCS is part of national strategy There is need to organise stewardship activities into systematic policies, programmes and guidelines as comprehensive AMSP. Also, laboratory support to inform clinical decision making for AMU has to be enhanced 5.2 IPC programme in health-care setting NA 3 National IPC policy, committee and guidelines are available and used to train professionals. Every hospital has an Infection control committees that investigate episodes of infectious diseases outbreaks and report to MoPH. Twice a year monitoring and inspection of IPC activities is conducted by MoPH. Surveillance data too is available. However, data not analysed to inform decision making Strengthen data analysis, training of infection prevention staff and use of information technology. Strengthen laboratory capacity for AST from provincial level and above – training in standard techniques, infrastructure. Surveillance data must be analysed regularly. 53 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5.3 National HAI and related AMR surveillance NA 3 Guidelines are available for HAI surveillance by site of infection/unit/ settings in place in provincial and other referral hospitals. Data on HAI is collected regularly but not all surveillance data is analysed hence making it difficult to inform decision making processes. Further, there is limited laboratory support for infectious disease diagnosis and AST Strengthen laboratory capacity for AST from provincial level and above – training in standard techniques, infrastructure and improve national oversight for reporting structures and harmonisation of standards 5.4 Sanitation and hygiene NA 5 Complete nationwide coverage has been ensured with respect to sanitation and hygiene and safe water supply in institutions, hospitals, communities and schools. This is seen as a success model that can be replicated and upscaled across the country Maintaining the high level of coverage with continuous campaigns and ensuring funding for WASH programmes will ensure long term sustainability and results 5.5 Vaccination NA 1 PCV vaccination is not available/ introduced in DPRK. However, influenza vaccine is included in the EPI programme Raise the issue of PCV introduction with partners and explore possibility of PCV introduction through WHO Country office/GAVI/other sources 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding NA 1 A research and development team of professionals has been constituted as part of the national AMR multisectoral committee, though it does not focus on AMR surveillance in the animal and human sectors. The research priority is to develop traditional medicines as alternatives to antimicrobials. Build research agenda in NAP and develop research capacity for surveillance to track the use of antibiotics in humans and animals. 54 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animals NA 1 There is no policy or regulatory framework for the control and registration of use in animals exists. Through the network of development partners (FAO/ OIE), align guidelines for antimicrobial sale and use in the veterinary sector with international standards and focus on capacity-building for the enforcement of drug regulations in the animal sector. Build awareness among animal health sector professionals and the Member States on the use of the tool developed by FAO for communication on AMR. Include AMR and prudent use of antimicrobials in the curriculums for human and animal health. Strengthen laboratory support for AMR surveillance in the animal sector. It is important to develop standard protocols and methodology for laboratory diagnostics in accordance with international guidelines, and focus on capacity-building and quality assurance to attain the highest performance standards. 7.2 National surveillance of AMR, and use and sale of antimicrobials in veterinary sector NA 1 There are no policy or guidelines for surveillance of AMR in the animal sector. The national guidelines for AM sales/use in the animal sector are not aligned with OIE. Same as 7.1 7.3 Biosecurity (IPC) in animal sector NA 3 General guidelines for biosecurity in the animal sector are implemented, and there are regular reporting mechanisms and a system to monitor compliance. National epizootic disease monitoring with specimen referral systems have been operationalized. Same as 7.1 7.4 AMR awareness generation and education in animal sector NA 1 No activities for raising awareness regarding AMR have been planned in the animal sector. Same as 7.1 55 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.5 A National AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 There is no policy or regulatory framework to control the release of AR/ AMR into the environment. Enhance the engagement of the environment sector, define standards for the release and management of antimicrobials in the environment, and link the existing policies with AMR-related issues. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1 The existing environment protection policy does not include AMR. No guidelines have been developed for surveillance of AR/AMR in waste and environment. Same as 7.5 7.7 AMR awareness generation and education in environmental sector NA 1 No specific policies have been developed to address AMR- related environmental issues. Same as 7.5 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 2 A national AMR coordination committee has been established, involving the relevant sectors, including health (human and animals), drug regulatory authorities, environment, education, food safety, quality control and mass media. Ensure the inclusion and engagement of all relevant sectors, including human and animal health, agriculture, aquaculture, food safety, environment and education, along with active participation of the civil society and media. It is vital to have a functional overarching AMR coordination mechanism in place. 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 1 The NAP-AMR engages stakeholders from various sectors, such as human health, animal, environment, education, quality control committees for medicine, food and mass media. Same as 8.1 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 1 Information on AMU in human health facilities is collected annually. No data are available for AMU in the animal sector and there is no mechanism for sharing data across sectors. Data on AMU and consumption should be shared regularly amongst all relevant sectors, with national and international stakeholders to enable evidence- based policy decisions and to track AMR transmission. 56 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance Fig 15: Situational analysis for progress on AMR prevention and containment at DPRK in 2018 Good practice Access to a safely managed water supply and nationwide coverage of sanitation and hygiene as well as WASH practices constitute a successful model. These steps have enabled the country to achieve a considerable level of advancement in the implementation of preventive measures. These achievements underscore the role of these steps in combating an AMR situation that is evolving by the day. Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.4 A platform and/ or mechanism for sharing of AMR surveillance data from all relevant sectors NA 1 There is no sharing of AMR data across various sectors. A framework is being identified for sharing information under the NAP-AMR. It is the need of the hour to develop platforms for sharing data from AMR surveillance in human and veterinary sectors to assess the magnitude of AMR in the country, identify gaps in AMR containment activities and develop operational plans to address challenges. 8.5 AAW is nationally coordinated and celebrated with involvement of and contribution from all relevant sectors NA 1 No AAW has been observed. However, it is planned to conduct a nationally coordinated AAW with contributions from various stakeholders. Develop communication strategies using standardized information, education and communication (IEC) material for generation of awareness on antimicrobials and behavioural change. AAW should be nationally coordinated, with the involvement of and contribution from all sectors. 8.6 A mechanism for co-sharing resources for AMR initiatives NA 1 No specific resources have been identified for AMR. WASH and IPC initiatives have been identified for co-sharing of resources to conduct AMR- related activities. Identify resources to implement AMR containment activities and explore sharing of resources across ministries for organizing key activities on a rotational basis. 57 India Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 2 3 The NAP is in line with the GAP- AMR, governance mechanisms on AMR have been established and a phased approach has been adopted for implementation, beginning with surveillance. There is a need for stronger advocacy with policy-level decision-makers to allocate separate funds for AMR activities in different sectors. 2. Raising awareness 2.1 Awareness campaigns for the public 2 2 Some government-led activities have been conducted in parts of the country to raise awareness of AMR. Develop a national strategy for mass awareness and conduct a survey to assess the impact of the awareness campaigns on the knowledge, attitude and practices of the public. The efficacy of the redline campaign, an innovative approach for antimicrobial containment in India, should be evaluated. There is a need for secure sustainable funds and political commitment to support generation of awareness across all sectors. 2.2 Education and training strategies for professionals 2 3 AMR forms a part of continuous professional development courses for health-care professionals. The Medical, Nursing and Pharmacy Council has been set up to review medical training and curriculum. To build awareness of the containment of AMR among professionals of the human health sector, it is recommended that awareness programmes, workshops and training for basic health staff be reviewed and developed. As the topic of AMR is included in the curriculum and continuous professional training, it is important to develop a competency framework as a way forward. 3. National AMR surveillance system 3.1 National human AMR surveillance 2 3 An AMR surveillance network, including a large number of tertiary hospitals in the public sector and a limited number of private hospitals, has been established. It contributes data to GLASS. The surveillance is yet to be sensitive and representative. Also, its contribution to GLASS is limited. For human AMR surveillance to be representative of the country, include additional sites to the surveillance network. Member States should consider capacity- building in data management and expand the use of WHONET. 58 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3.2 Strengthening of national laboratory network 2 4 A national laboratory network has been established. The CLSI has been adopted as the reference standard and EQAS has been set up at all surveillance sites. Develop standardized protocols for laboratory diagnostic methodology and quality assurance procedures. Organize training for the laboratory network supporting AMR containment 3.3 Early warning systems 2 2 A list of priority AMR bacteria has been drawn up and molecular methods are available. However, reporting to GLASS-EAR is still in the initial phase. Operationalize EWS, develop a national repository of AMR strains and set up auto-generation of alerts, using a real-time IT-based AMR data management platform. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 3 2 A national policy for the containment of AMR has been developed and an AMSP planned. Develop national guidelines for antimicrobial stewardship. This should include monitoring tools to assess the impact of training and explore web-based training and resources to conduct nationwide training on stewardship. 4.2 NRA/ DRA 4 4 The Drug Controller General of India and Central Drugs Standard Control Organization (CDSCO) is the NRA. Tools for quality assurance and registration of antibiotics are in place, and inspection is implemented. However, the capacity for enforcement of policies and regulation is limited. Promote regulatory cooperation on AMR in SEARN for imports of medical products (medicines, devices and diagnostics) and regulatory cooperation in laboratory network. 4.3 Surveillance of antimicrobial use and sales among humans 3 3 Sales of antimicrobials at the national level have not been monitored. Monitoring of use is limited to few facilities that are not representative. To establish AMU surveillance in the human health sector, it is crucial to develop a national AMU monitoring system with technical assistance from the development partners. Member States should consider organizing a national workshop on surveillance of antibiotic consumption using the tool prepared. 4.4 Regulation of finished antibiotic products and APIs 4 4 The CDSCO is the regulatory authority. Inspection is implemented, but there is limited capacity for enforcement of policies and regulation. Enhance engagement with the department of pharmaceuticals and get the CDSCO to conduct an assessment to generate evidence on the quality of drugs, and to support good microbiological practices. 59 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 4.5 Regulation of pharmacies regarding OTC sale and inappropriate sale of antibiotics and APIs 4 4 The CDSCO is the regulatory authority in place. Inspection is implemented, but there is limited capacity for enforcement of policies and regulation. Strengthen the regulatory capacity of the NRA to implement regulation of OTC sales and inappropriate sale of antibiotics and enforce regulations pertaining to finished products and APIs. 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 3 1 There is no national comprehensive policy for AMR stewardship. Standard treatment guidelines and IPC guidelines have been developed. Prepare national guidelines for an IPC programme, and integrate AMSP and HAI surveillance with the IPC programme in health- care facilities. Build the capacity of nursing staff so that they can successfully implement the IPC programme nationwide. The Member States should work towards convergence of the surveillance conducted for AMR, AMU and HAI. 5.2 IPC programme in health-care setting 3 3 A national patient safety framework /IPC is implemented in selected health-care facilities. Same as 5.1 above 5.3 National HAI and related AMR surveillance 3 3 Few public and private facilities have HAI surveillance and share data with bodies at the national level. Same as 5.1 above 5.4 Sanitation and hygiene 4 3 Policies/ campaigns to improve sanitation and hygiene are implemented on a limited scale. Data on safely managed water supply or sanitation services exist, but there is not much access to these. For the promotion of sanitation and hygiene, it is advisable to strengthen the implementation of WASH through IPC arrangements at health facilities. Emphasize promotion, along with M&E of the Swacch Bharat Abhiyaan and Kayalap, which have been recognized as good practices. Member States should promote routine immunization and include AMR as a topic of discussion for the immunization technical advisory group. 5.5 Vaccination NA 3 PCV 13 has been implemented partially under Mission Indradhanush. Typhoid and PCV are used extensively in the private sector. Continue routine immunization activities across the nation and expand the PCV vaccination programme to areas with a high burden of disease. 60 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 2 2 The NAP outlines research and development policies. There are various R&D activities under way, in collaboration with international agencies and development partners. Develop an AMR research consortium to strengthen partnerships with research/ academic institutions, civil society and other stakeholders, for resource mobilization and the development of evidence- based policies. The research activities to focus on impact the assessment of AMR containment initiatives to support NAP-AMR implementation. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for the control and registration of use in animals 2 2 A national plan on AMU has been developed by the DRA for the veterinary sector. A regulatory framework for the registration of products and AMU in the animal sector has been developed, but is not being implemented. Develop a regulatory framework under the Drugs and Cosmetics Act to control the use of antimicrobials in the animal sector. To initiate national surveillance of AMU and sale in the veterinary sector, advocate establishing a drug supply chain from the manufacturer to distribution outlets. This should also include import information. To support AMR surveillance in the veterinary sector, it is imperative to build the capacity for laboratory diagnostics, build on the infrastructure available and ensure the management of data. 7.2 National surveillance of AMR, and use and sale of antimicrobials at national level in veterinary sector 1 AMU1; AMR2 There are no policy/ guidelines for surveillance of antimicrobial sales and AMU. There is a limited capacity for AMR surveillance in the animal sector. An Indian network of fisheries and animal research on AMR has been established. There are plans to outline SOPs and methodologies for AMR surveillance in the animal sector. Same as 7.1 above 61 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.3 Biosecurity (IPC) in animal sector 2 3 A biosecurity manual is being followed by public and limited private facilities in the animal sector, particularly the poultary set-up. Training for the animal sector, such as the fisheries department, is well established. An online reporting mechanism has been developed. To ensure biosecurity in the animal sector, it is essential to develop a national biosecurity manual with good husbandry practices, ensure monitoring compliance and harmonize national AMR containment activities. 7.4 AMR awareness generation and education in animal sector 2 1 There is no national strategy for the generation of awareness of AMR in the animal sector. The veterinary curriculum has been modified to include topics in microbiology that emphasize AMR. There are limited activities for raising awareness, such as training for veterinarians. Develop a strategy and guidelines on raising awareness among veterinarians of the prudent use of antimicrobials. Align awareness campaigns with regulatory framework. Focus on the use of mass communication techniques and the social media platform to reach farmers in far-flung areas. Initiate the inclusion of AMR-related issues in the curriculum for veterinary professionals. 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 Biomedical waste management guidelines exist and guidelines to reduce AR in industrial effluent are under way. No regulations have been developed to control AR emissions from antimicrobial manufacturers, hospitals and waste-water treatment plants. Expedite the finalization of standards to control the release of AR and AMR into the environment and include the same in the national AMR containment policy. Review private sector initiatives and involvement in reducing AR in effluents. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1+ The policy guidelines are weak and evidence linking AMR and the environment is limited. National surveillance of AR and AMR in waste water requires establishing a national authority for the containment of AMR and bridge the gap in impact of AMR in the environment. 62 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.7 AMR awareness generation and education in environmental sector NA 1 There are no targeted communication strategies on AMR in waste. Guidelines for AR monitoring are being developed. Create awareness of efficient management of biological waste products, including manure, in the context of AMR containment. Strengthen community-level management of the disposal system for unused/expired antimicrobials on farms and in households. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism exists between all relevant sectors NA 2 A multisectoral AMR steering committee and a national authority for the containment of AMR have been established with the participation of the relevant sectors, including human and animal health, food safety, environment and the civil society. To establish multisectoral committee for overarching AMR coordination by engaging all relevant stakeholders including environment, food safety, agriculture and WASH programme across the country including at State level. 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 3 The NAP-AMR provides for the inclusion and engagement of relevant sectors such as food, animal husbandry, dairy, fisheries, environment, civil society and education and research development. Same as 8.1 8.3 A platform and/ or mechanism for sharing AMU monitoring data from all relevant sectors NA 1 There is no mechanism for sharing AMR surveillance data from all the relevant sectors. The NAP-AMR plans to monitor AMU at the national and state levels. To develop multisectoral integrated monitoring and surveillance mechanisms for the use and sale of antimicrobials in the human, animal and plant sectors. 8.4 A platform and/ or mechanism for sharing AMR surveillance data from all relevant sectors NA 2 In the human health sector, a system is in place for AMR surveillance. In the animal health and food sectors, AMR surveillance is in the intial phase of establishment. There is no platform for the sharing of data between sectors. To enable evidence-based policy decisions, it is of paramount importance to streamline data flow and develop platforms for the regular sharing of AMR surveillance and AMU/sales data with all national and international stakeholders across all relevant sectors. 63 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 1 AAW is celebrated primarily in the human health sector. There are plans to establish linkages with WASH, animal and evironment sectors. Build synergies amongst all the relevant sectors to organize a nationally coordinated AAW with a focus on standardized and uniform communication strategies aimed at behavioural change. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 1 No formal mechanism has been established for the co-sharing of resources for AMR initiatives in the country. Member States to map available resources, develop operational plans and establish mechanism for the co-sharing of resources for AMR initiatives. - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance 2016 2018 Fig 16: Situation analysis of progress in AMR prevention and containment in India, 2016–2018 Good practice The Swachh Bharat Abhiyaan (Clean India Mission), Kayalkalp (rejuvenation) and Swach Swasth Sarvatra (war against impurity) initiatives of the Government of India have been highlighted as good practices for spreading awareness and knowledge of AMR. These activities encourage behavioural change among different audiences and the active engagement of all sections of society for effective promotion of hygiene and IPC programmes. The concept of marking a red line on antibiotic packages to curb OTC sale is considered a model for creating awareness on the dangers of taking antimicrobials without prescription, especially in countries with non-existent or weakly enforced laws pertaining to OTC sale of drugs. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 64 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Indonesia Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 3 2 The NAP is in line with GAP-AMR and developed with multisectoral collaboration, in line with the One Health approach, supported by WHO, FAO and OIE. To strengthen the NAP-AMR operational plan, it is crucial to build an M&E framework. There is a need for stronger advocacy with policymakers to allocate separate funds for AMR activities in different sectors. 2. Raising awareness 2.1 Awareness campaigns among the public 3 4 Public awareness campaigns on the prudent use of antimicrobials have been conducted with a focus on health professionals working in the human and animal health sectors. The dissemination of information and educational material for increasing public awareness and knowledge, through the print, electronic, and social media have been conducted nationwide. AAW is organized regularly by the MoH, with support from development partners in the health sector. Efforts should be made to continue and expand the public awareness campaign at the community level and evolve a methodology to assess the impact of public awareness campaigns regularly. Member States to conduct a baseline impact evaluation of public awareness campaigns on AMR in 2019 . 2.2 Education and training strategies for professionals 3 3 AMR has been included in scientific seminars of professional associations, workshops, and training and technical assistance sessions for health-care professionals. To educate and train professionals catering to human health, include AMR in the curriculum for all health professionals, including pharmacists, technicians, nurses and focus on AMR during all trainings and continuous professional development courses. 3. National AMR surveillance system 3.1 National human AMR surveillance 2 2 Guidelines have been developed but not fully implemented. The availability of quality data and analysis is limited. Develop a policy for the surveillance of AMR in the human health sector, with a focus on monitoring systems and data analysis at the national level. 65 Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 3.2 Strengthening of national laboratory network 1 1 No national network has been developed. The national veterinary product assay laboratory conducts AMR surveillance of livestock. There is a need for establishing a laboratory network with a designated national reference laboratory that supports laboratory diagnostics nationwide. It is recommended that international standards of AMR detection, including external quality assurance for laboratory surveillance, be adopted. 3.3 Early warning systems NA 1 There is no AMR-specific EWS. Disease-specific warning systems (for TB, HIV) have been developed. Develop a plan to establish an early warning system for emerging resistance on a national scale and expand the list of priority AMR bacteria to include organisms identified from specimens apart from blood. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 4 2 A national AMSP has been planned and is under development. There is a list of essential medicines and a national formulary which places restrictions on AMU in health- care facilities. To strengthen the implementation of the AMSP nationwide, update the guidelines on AMU. Explore the introduction of prescription audit, feedback mechanisms and expansion of the AMSP to private health-care facilities. 4.2 NRA/ DRA 4 5 The NADFC conducts pre- and post-market control of antimicrobial medicines as part of quality assurance activities. The NADFC enforces GMP, good distribution practices (GDP) and good pharmacy practice (GPP), particularly to ensure quality standards production, distribution and management of medicines in health-care facilities. There is a cyber patrol to control online sales of drugs. Promote regulatory cooperation on AMR in SEARN for the import of medical products (medicines, devices and diagnostics) and regulatory cooperation in the laboratory network. Ensure the availability of adequate financial resources and trained manpower at the NRA for optimal performance and support the implementation of NAP-AMR. 66 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 4.3 Surveillance of AMU and sale among humans 3 3 The sale of antimicrobials at the national level is not being monitored. Monitoring of AMU is limited to a few facilities that are not representative. It is conducted in a few puskesmas as an indicator of the rational use of medicines for two diseases – non-pneumonia ARTI and acute diarrhoea, and regularly reported to the MoH. To establish AMU surveillance in the human health sector, it is essential to develop the national AMU monitoring system with technical assistance from the development partners. 4.4 Regulation of finished antibiotic products and APIs NA 5 A regulatory authority and system are in place, and regulation is fully and effectively implemented. Strengthen the NRA’s capacity to maintain regulatory control of finished antibiotic products, APIs and OTC sales of antibiotics. 4.5 Regulation of pharmacies regarding OTC sale and inappropriate sale of antibiotics and APIs NA 4 A regulatory authority and system are in place. Inspection is implemented, but there is limited capacity for the enforcement of regulation. Finalize regulations for online sale of medicines and continue to expand the community movement on the smart use of medicines programme. 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 3 3 There are no national policy/ guidelines on stewardship. National IPC/AMR plan aligned. IPC/AMR plans implemented in a limited number of health-care settings. Develop a national policy on AMSP, allocating an adequate budget and using sufficient human resources for nationwide implementation. 5.2 IPC programme in health-care setting 3 3 An IPC programme is implemented in select health- care facilities. It includes the rational use of antibiotics, guidelines, standard and transmission precautions, education and training, HAI surveillance and capacity- building plans. In consultation with technical experts, prepare guidelines on training and a reporting system for data management, and integrate IPC with AMSP in health-care setting. 5.3 National HAI and related AMR surveillance 2 2 Few public and private facilities have HAI surveillance. Data are not centralized at the national level . Prepare specific technical guidelines for HAI and standardize HAI-related AMR surveillance in the country. To support HAI surveillance, it is essential to set up a laboratory network with close monitoring and supportive supervision to maintain the highest performance standards. 67 Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 5.4 Sanitation and hygiene NA 4 A policy /WASH campaign to improve sanitation and hygiene is implemented at a large scale. Data on safely managed water supply or sanitation services exist, but access to these data is medium. The Member States should strengthen their sanitation and hygiene campaign, consider a detailed survey on WASH in health-care settings and build advocacy for the nationwide expansion of the WASH programme. 5.5 Vaccination NA 2 PCV has been introduced in some provinces of the country. In general, there is vaccination coverage of more than 90%. Continue routine immunization activities across the nation and conduct evidence-based expansion of the PCV vaccination programme to provinces with a high disease burden. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 2 2 Policies have been planned and the existing structure proposes to foster research and innovation on AMR. Strengthen coordination and collaboration amongst various stakeholders and laboratory networks to formulate a coherent R&D policy and ensure the availability of technical and financial funds, to conduct targeted research focused on AMR. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animals 2 3 Policies and regulations have been established on AMU in the livestock and animal health sector, but there is limited capacity for monitoring registration and AMU. The Member States may consider including the assessment of biosecurity measures during routine inspections.To focus on biosecurity in the animal sector, it is suggested that awareness campaigns be conducted for small-scale farmers, and concepts of biosecurity be included in continuous professional development courses for veterinarians and audit learning after training. Ensure sustainability by providing adequate human and financial resources. 68 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 7.2 National surveillance of AMR, and use and sale of antimicrobials in veterinary sector 2 AMU-3 AMR-3 Surveillance of the sale, distribution and use of antibiotics is limited and not yet integrated. Surveys of antibiotic sales were based on data on the import and production of antibiotics, while no comprehensive correlation survey has been conducted between sales data and usage data. A national strategy is being developed on AMR surveillance in the veterinary sector and capacity-building. Same as 7.1 above 7.3 Biosecurity (IPC) in animal sector 3 4 Continuous professional development in AMR and alternative biosecurity measures and regular audit of learning are being carried out. Though M&E mechanisms are functional, their contribution is suboptimal for improving the capacity of the system and ensuring sustainability. Same as 7.1 above 7.4 AMR awareness generation and education in animal sector 1 3 AMR awareness programmes have been developed and piloted in some pre-service veterinary training and a few special courses for veterinary faculty, both in the public and private sectors, among farmers and stakeholders from the poultry association. Stronger advocacy with academia is requied for the generation of AMR awareness in the animal sector so that the subject of AMR is included in the curriculum and continuous professional development courses for veterinarian and farming professionals. Adopt a multisectoral approach by involving the marine and agricultural sectors to generate awareness of efficient management of waste water in the context of AMR. 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 There is no national policy to reduce antimicrobial contamination of the environment and no regulations controlling AR emissions have been developed. Review the existing regulations on solid waste and waste water management to control the release of AR /AMR into the environment. Advocate the integral role of the Ministry of Environment in developing policy and a regulatory framework for AMR containment and management. 69 Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1 Though the environment sector is engaged in AMR activities, there are no regulations on AR and AMR monitoring in the environment. Strengthen community-level management of the antimicrobial disposal system of unused antimicrobials at the farm or household level. 7.7 AMR awareness generation and education in the environmental sector NA 1 No policies/communication strategies have been developed to limit the disposal of antimicrobials in the environment and to monitor the impact of AMR in waste. Enhance the engagement of the environment sector and link the existing policies with AMR-related issues to make evidence-based policy decisions. The Member States should conduct national surveillance with technical support from development partners to generate a country profile of AR and AMR in the environment and identify indicators for monitoring AR and AMR in waste water form all relevant sectors. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 1 There is no policy for the regulation of multisectoral coordination. The NAP outlines a multisectoral coordination mechanism, but it is yet to be implemented. To enhance multisectoral collaboration, involvement and engagement of all relevant sectors, there is a need to set up a coordination committee and have the NAP-AMR endorsed by the government. 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 2 NAP-AMR provides for inclusion and engagement of various sectors, including the human health, animal health, food safety, civil society and trade sectors, along with private sector engagement. Same as 8.1 8.3 A platform and/ or mechanism for sharing AMU monitoring data from all relevant sectors NA 1 There is no regulation policy/ mechanism/ platform for sharing AMU data among the relevant sectors. Develop multisectoral integrated monitoring and surveillance mechanisms for the use and sale of antimicrobials in the human, animal and plant sectors. 70 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase 2016 Phase 2018 Justification/ comments Recommendations 8.4 A platform and/ or mechanism for sharing AMR surveillance data from all relevant sectors NA 2 There is no existing mechanism for sharing AMR surveillance data from all relevant sectors. The Ministry of Agriculture conducts AMR surveillance of livestock and data from the national reference laboratory is shared with the central government. To enable evidence-based policy decisions, it is of paramount importance to streamline data flow and develop platforms for regular sharing of AMR surveillance data with all national and international stakeholders across all relevant sectors. Focus on finalizing the tricycle project. 8.5 AAW is nationally coordinated and celebrated with the involvement of and contributions from all relevant sectors NA 1 AAW activity is nationally coordinated, but there is no multisectoral integrated approach. Build synergies amongst all relevant sectors to organize a nationally coordinated AAW. To ensure standardized communication, it is suggested that messages prepared by the Tripartite at the international level are adapted to the country’s context. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 1 There is no sharing of resources for AMR initiatives. To conduct AMR activities, budget provisions are made by the MoH, but there is no dedicated fund for AMR activities in the Ministry of Agriculture. The Member States should identify available resources, develop operational plans and establish a mechanism for the co-sharing of resources for AMR initiatives. 71 2016 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance Fig 17: Situational analysis of progress in AMR prevention and containment in Indonesia, 2016–2018 Good practice The remarkable performance of the NADFC in pre- and post-market control of antimicrobials as part of quality assurance activities is one of the good practices highlighted in Indonesia. The NADFC ensures the quality of antimicrobials by routine inspection of production and distribution facilities, including pharmacies and health-care facilities, and by testing samples in NADFC laboratories, both in central and provincial offices. The NADFC regulatory enforcement in the areas of import, export, production, distribution and use of finished antibiotic products and APIs ensures compliance with GMP, GDP and GPP, particularly as far as the management of the safety, efficacy and quality of medicines is concerned. There is a strong system of pharmacovigilance, with adverse drug reactions being reported to the NADFC through e-meso application. Another good practice that deserves special mention is the community movement, the “smart use of medicines programme”, which emphasizes the prudent use of AMR by enhancing awareness among pharmacists and the community regarding the sale of antibiotics only on prescription. An average of phase-grading for all indicators in different focus areas is shown in the figure purely for pictorial representation. 72 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Maldives Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 2 4 The NAP is in line with GAP- AMR. Budgetary provisions have been made for all activities in the standard budget of the MoH. A national AMR multisectoral coordination committee, with technical subcommittees, has been established and is functional. A high-level ministerial steering committee for AMR has been approved. Prioritize the endorsement of NAP-AMR by all ministries concerned, including agriculture, fisheries and environment, along with the animal and human health sectors. Step up targeted advocacy with policy-level decision-makers to mobilize resources and create synergies with the existing programmes for AMR containment. 2. Raising awareness 2.1 Awareness campaigns for the public 2 3 Nationwide awareness campaigns have been conducted annually since 2015. There are plans for a nationwide survey to assess the knowledge, attitudes and practices of health-care workers and the public at large. Consider undertaking a knowledge, attitudes and practices survey to have baseline information on AMR awareness among the public. Develop targeted communication strategies for behavioural change with specific M&E framework. Explore using the social media for advocacy and consider appointing an ambassador to promote the cause of AMR among the public. 2.2 Education and training strategies for professionals 1 3 AMR is included in the curriculum of nurses, laboratory technicians and pharmacists. Develop a specific curriculum for health-care professionals, including experts in the fishery, plant and environment sectors. 3. National AMR surveillance system 3.1 National human AMR surveillance 2 2 The data available from standardized surveillance initiated at a few tertiary hospitals are limited. Standard operating procedures and guidelines for a nationwide surveillance system are under development. Strengthen the IT sector to support national human AMR surveillance. 73 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3.2 Strengthening of national laboratory network 1 2 A national network of 20 laboratories in a 4-tier health- care system is planned. A national reference laboratory has been identified, standard operating procedures are in place for diagnostics in accordance with the CLSI guidelines. Capacity for the molecular identification of AMR bacteria is not developed. A quality framework including EQAS is under way. Build capacity of the laboratory network supporting AMR, with a focus on developing standardized methods and quality control procedures. Establish mechanisms for regular and timely sharing of microbiological findings with programme experts and build a stronger coordination between laboratory and programme staff. 3.3 Early warning systems 1 1 There is no EWS. Build capacity for the molecular verification of identified AMR organisms to establish EWS. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 2 2 The national AMSPhas been planned and is under development. Expedite the implementation of the AMSP. Consider the inclusion of prescription audit and establish a drug therapeutic committee at hospitals. 4.2 NRA/DRA 3 4 Tools for quality assurance and registration of antibiotics are in place and inspection implemented, but the capacity for the enforcement of policies and regulation is limited. Ensure availability of adequate financial resources and trained manpower for the Food and Drug Authority to support the implementation of the NAP-AMR optimally. 4.3 Surveillance of AMU and sale among humans 2 3 The monitoring of antimicrobial sales at the national level has not been implemented. The monitoring of use is irregular and limited to a few facilities that are not representative. Identify resources for capacity building and establishing systematic surveillance of AMU and sales in humans. 4.4 Regulation of finished antibiotic products and APIs 2 4 A regulatory authority and system are in place and inspection is implemented, but the capacity for the enforcement of policies and regulation is limited. Strengthen capacity of NRA to implement regulation of OTC and inappropriate sale of antibiotics and enforce regulations on finished products and APIs. 4.5 Regulation of OTC sale and inappropriate sale of antibiotics and APIs by pharmacies 2 4 A regulatory authority and system are in place and inspection implemented, but the capacity for the enforcement of policies and regulation is limited. Same as 4.4. 74 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 1 1 A national AMSP has been planned and is under development. The national AMR containment policy is in the final stage of endorsement. Expedite the preparation of national guidelines for the IPC programme and integrate AMSP and HAI surveillance with the IPC programme at health- care facilities. Set up drug and therapeutics committees in hospitals and plan trainings for capacity-building or retaining and/or recruiting of infection control specialist. 5.2 IPC programme in health-care setting 2 2 A national patient safety and infection control committee has been established in the MoH. Though guidance documents for infection prevention are available, they need to be formally endorsed, so are not yet implemented. A national committee needs to be set up to elaborate policy and strengthen laboratory capacity to support IPC in health-care setting. 5.3 National HAI and related AMR surveillance 2 1 A national AMR containment policy has been developed, but is yet to be endorsed by all stakeholders. Establish a specific HAI surveillance system with guidelines, including M&E aspects. 5.4 Sanitation and hygiene 2 4 Training and awareness- raising sessions on sanitation and hygiene are conducted in the community at large scale for diseases such as flu and diarrhoea. Access to safe water is ensured for the entire population. Strengthen the surveillance of waste water for microbial content and antibiotic residue. Promote WASH activities nationwide. 5.5 Vaccination NA 1 Plans are under way to introduce PCV in 2018. A low incidence of typhoid was reported by the disease surveillance system, so typhoid vaccination is not being considered. Introduce PCV as planned. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 1 2 Policies have been framed and the existing structure has a plan to foster R&D. Promote R&D to understand the baseline AMU/AMR status in the country. Develop innovative measures to reduce contamination by cross-border microorganisms. 75 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for the control and registration of animal use 2 1 There is no national policy or plan to reduce AMU in the animal or fisheries sector. The national AMR containment policy is in the final stage of endorsement. Streamline data generated from AMR/AMU surveillance and develop mechanisms for systematic data sharing with national and international stakeholders. 7.2 National surveillance of AMR, and use and sale of antimicrobials in the veterinary sector 3 AMU-1 AMU-2 There is no system for collecting data on AMU in animals. No reports have been submitted to the OIE on AMU in the animal sector due to the non-availability of data. The AMR containment policy includes AMR surveillance in animals. However, no activities have been conducted for want of infrastructure, skilled manpower, guidelines and SOP for laboratory activites in the animal sector. The laboratory capacity with respect to food and water is limited. An aquaculture centre with laboratory facilities is being developed. Member States should establish a mechanism for the collection and analysis of data on AMU in the veterinary sector at the national level. 7.3 Biosecurity (IPC) in animal sector 1 1 There are no AMR-specific biosecurity policies, though general guidelines on biosecurity (for poultry, small ruminants but not aquaculture) have been developed and partially implemented. Biosecurity guidelines specific to AMR in the animal sector, including aquaculture, should be developed. The Member States should consider the inclusion of biosecurity measures in inspection services and visits. 7.4 AMR awareness generation and education in animal sector 1 1 The national AMR containment policy (in final stage of endorsement) focuses on the education of farmers, food handlers and the food industry. The draft agriculture policy addresses AMR awareness among farmers. Continue advocacy and awareness activities for farmers, pet owners and health professionals in veterinary sector. 76 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 A national AMR containment policy is in the final stage of endorsement. There is no national framework to control release of AR and AMR into the environment and management therein. With the aid of technical assistance, develop solutions for waste management and the release of AR and AMR in environment . 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human,animal, fish sectors and disposal by institutions and homes NA 1 The ministry of environment is part of the national coordinating committee on AMR. Mechanisms need to be developed for the disposal of waste generated from AMU to ensure environmental safety. Develop mechanisms for the disposal of waste generated from AMU to ensure environmental safety. Link the existing environmental policies and regulations with AMR containment. 7.7 AMR awareness generation and education in environmental sector NA 2 The national AMR containment policy addresses awareness and education of the environment sector. No targeted strategies have been developed for environmental safety. Increase the involvement of fisheries, farmers and school students to enhance the generation of awareness and education in the environmental sector. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 2 A national AMR coordination committee was established in 2016. It comprises subcommittees on education, awareness, surveillance, AMU, research and innovation, and an expert group on IPC, which includes representatives from the private sector. AMR steering committee approved with ministerial level participation from education, environment, agriculture and fisheries, finance and health sectors. Develop collaborative mechanisms with relevant stakeholders to build legal framework for controlling antimicrobial use in agriculture, aquaculture and veterinary sector. 77 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 2 The NAP-AMR provides for the inclusion and engagement of the health, education, environment, agriculture and fisheries, finance, food safety sectors and WASH. Same as 8.1 8.3 A platform and/ or mechanism for sharing AMU monitoring data from all relevant sectors NA 1 Estimates on AMU in the human sector can be made by extrapolation of the import database as all medicines are imported.. Establish mechanisms for the systematic sharing of AMR surveillance/ AMU monitoring data among all relevant stakeholders. 8.4 A platform and/ or mechanism for sharing AMR surveillance data from all relevant sectors NA 1 AMR surveillance data from a few tertiary hospitals have been shared on WHONET. No structured surveillance set up for animal, fisheries, agriculture, food and environmental sector. Same as 8.3 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 3 AAW is nationally coordinated and celebrated with the involvement of all sectors, including education, environment, agriculture and fisheries, finance and health. Events for human health are scheduled even beyond AAW. Build ownership and strengthen coordination amongst various stakeholders during AAW celebrations. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 2 The initial mapping of responsibilities and identification of stakeholders was conducted, but as a mapping of financial resources was not carried out, there is no co-sharing of resources for AMR initiative. The Member States should map available resources, develop operational plans and establish a mechanism for the co-sharing of resources for AMR initiatives. 78 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 2016 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance Fig 18: Situational analysis of progress in AMR prevention and containment in Maldives, 2016–2018 Good practice Among the good practices that can reverse AMR trends in Maldives are the efforts towards capacity-building of professionals and para-professionals in the human health sector. Apart from modifying the curriculum for nurses, laboratory technicians and pharmacists, the country organizes continuing medical education courses focused on AMR for health-care professionals every week. The efforts to check the use of illegal veterinary drugs, especially in private set-ups, should go a long way in curbing the indiscriminate use of antimicrobials. The adoption of quality management systems as per ISO 9000:2015 for the regulation of medicines is another good practice. The figure shows an average of phase-grading for all indicators in different focus areas purely for pictorial representation. 79 Myanmar Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 2 3 A NAP has been developed in line with the GAP- AMR. A national multisectoral AMR steering committee and national technical committee have been established and are functional. The Member States should link the existing organizational structure with the operational plans, and ensure an inbuilt framework for M&E and adequate resources. 2. Raising awareness 2.1 Awareness campaigns for the public 2 3 Nationwide activities on AMR awareness generation are conducted for the public through collaborative efforts of the human health and veterinary sectors. Develop a national strategy for comprehensive awareness of AMR. This should include a survey to assess baseline information on AMR. Secure sustainable funds and support from ministries other than health for conducting campaigns and generating awareness of evolving AMR. 2.2 Education and training strategies for professionals 2 3 AMR topics are included in some pre-service, in-service and other continuing professional development training courses for human health professionals. Conduct awareness programmes, training and workshops for all health professionals. There is a need for continuous medical education programmes to keep professionals up to date. Proritize building of AMR concepts for in- service health professionals and revise the medical curriculum to focus on AMR. 3. National AMR surveillance system 3.1 National human AMR surveillance 2 2 Few AMR surveillance sites have been established and registered in GLASS. Strengthen surveillance data management training conducted in WHONET while AMR surveillance guidelines are yet to be developed . Strengthen human AMR surveillance, streamline data management and set up a mechanism for regular and timely sharing of human AMR data with hospitals and national/ international stakeholders. 3.2 Strengthening of national laboratory network 2 4 A national reference laboratory has been set up with the CLSI as a refence standard and to support laboratory network. The repository system and national EQAS have to be established. To achieve and maintain the highest standards in laboratory performance, the Member States should establish laboratory accreditation practices and ensure the availability of the latest CLSI guidelines in the nation’s laboratory network. 80 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3.3 Early warning systems 1 1 No EWS are available. Develop an early warning system with the use of the latest technology to support epidemiological data analysis and to build the molecular diagnostic capacity of the laboratory network. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 1 1 There is no policy pertaining to AMR containment and control of human use of antimicrobials. There is no policy on AMR stewardship either. Promote regulatory cooperation in SEARN on AMR for import in medical products, and quality assurance of laboratory network. Develop an API analysis system. Strengthen the regulatory capacity of the NRA to implement regulations on OTC and inappropriate sale of antibiotics, and enforce regulations on finished products and APIs. 4.2 NRA/ DRA 3 3 The enforcement activities of the NRA are weak due to limited capacity and resources. Same as 4.1 4.3 Surveillance of AMU and sale among humans 2 2 There are no guidelines on the surveillance of the use and/ or sale of antimicrobials in humans. Same as 4.1 4.4 Regulation of finished antibiotic products and APIs 2 2 An NRA, with limited functional capacity, has been established for oversight. Same as 4.1 4.5 Regulation of pharmacies regarding OTC and inappropriate sale of antibiotics and APIs 2 2 Regulation of pharmacies regarding OTC and the inappropriate sale of antibiotics is in place, but there is limited capacity for implementation. Same as 4.1 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 2 2 There is no national AMR stewardship policy. The SOPs, guidelines and protocols are weak and not available at all health facilities. Develop AMR stewardship policy/ guidelines; and organize training/ workshops to promote the concept of AMR stewardship in health-care settings. 5.2 IPC programme in health-care setting 3 2 National IPC guidelines have been developed, and all hospitals have a hospital infection control committee. They also have basic IPC facilities, including laboratory support. The implementation of IPC guidelines is limited due to constraints of human resources. Establish an IPC programme with a dedicated trained staff at the national level and strengthen the hospital infection control committees. 81 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5.3 National HAI and related AMR surveillance 1 3 Limited surveillance is being conducted in some health-care facilities in accordance with the SOPs and guidelines developed for HAI surveillance. Consider the development of a national policy, allocating adequate human resources and funds to ensure the sustainability of activities initiated under HAI and related AMR surveillance. 5.4 Sanitation and hygiene 3 2 WASH activities are conducted in communities. There are limited data on safe water supply and sanitation services. Enhance compliance with sanitation and hygiene activities promoted nationwide under the WASH programme. 5.5 Vaccination NA 4 PCV 13 has been included in the EPI programme since 2016. There are no plans to include the Typhoid Vi vaccine. Advocacy is required to link AMR and vaccination practices. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 2 3 The NAP outlines research and development activities for AMR surveillance. Several research activities have been undertaken, but a fully operational AMR- oriented research programme is yet to be implemented. Establish a technical working group to develop operational research plans that support the implementation of NAP-AMR. Mobilize resources to ensure sustainable funds for R&D and innovation. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animals 1 1 There is no national policy to reduce AMU in the animal or fisheries sector. Develop a policy/ guidelines for AMR and AMU surveillance in the animal sector. Identify resources, ensure the availability of infrastructure and organize training for initiating AMR surveillance in the veterinary sector. Expedite the finalization of animal feed under drug law to provide a legal framework for the use of antimicrobials in the animal sector. 7.2 National surveillance of AMR, and use and sale of antimicrobials in veterinary sector 1 AMU-1 AMR-1 Project-based AMU/AMR surveillance is being conducted in a limited manner. There is no policy/guidelines for AMU/AMR surveillance. The draft animal feed law is yet to be finalized. The NAP outlines surveillance and monitoring activities, however these are yet to be implemented. Same as 7.1 82 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.3 Biosecurity (IPC) in the animal sector 2 1 Biosecurity policies, strategies and guidelines have not been prepared. Develop a biosecurity policy. Finalize and endorse guidelines on animal husbandry practices with a focus on backyard as well as commercial farms. 7.4 AMR awareness- generation and education in animal sector 1 1 There is no national strategy for comprehensive awareness generation in veterinary services. Create awareness of AMU and AMR among animal handlers. 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 There is no national policy to reduce antimicrobial contamination of the environment. Guidelines and SOPs for health-care waste management include pharmaceutical waste management, but these are not yet focused on AR or AMR. Review current regulations on waste water control and initiate a survey to assess the status of antibiotic residue and AMR at different locations in the country. 7.6 National surveillance of AMR in waste water from manufacture and use in the human, animal sectors and disposal by institutions and homes NA 1 No provision for monitoring AR and AMR in the environment. The Ministry of Natural Resources and Environmental Conservation is yet to be involved in AMR activities. Develop guidelines to enhance the engagement of the environment sector in the surveillance of AR and AMR in waste water from various sources. 7.7 AMR awareness generation and education in environmental sector NA 1 There is no policy or targeted communication strategy on AMR in waste for the public at large. The involvement and engagement of the Ministry of Natural Resources and Environment Conservation is imperative for comprehensive AMR containment efforts. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 2 Here is an overarching AMR coordination mechanism, with a national multisectoral steering committee, national coordination committee and technical working groups which are established and functional. Make the participation of various sectors more organized by avoiding duplication of activities by various committees. 83 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 2 The human health, animal health, plant health, food production, food safety, environment, WASH, trade and private sectors, as well as the civil society are included and engaged in the implementation of the NAP-AMR. Engagement of the environment, plant and food sectors should be strengthened. 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 1 There is no policy, mechanism or platform for the sharing of AMU data among the relevant sectors. Set up a platform for the regular sharing of data among the relevant sectors for evidence- based decision making at the national and international levels. 8.4 A platform and/ or mechanism for sharing of AMR surveillance data from all relevant sectors NA 2 Project-based AMR surveillance is conducted in the veterinary sector. AMR surveillance activities are limited in the human health sector. There is no mechanism/ platform for the sharing of data among various sectors. Human health surveillance data should be regularly shared with all the relevant sectors. Animal health surveillance should be established at the national level and pilot projects in the veterinary sector should be scaled up for animal health surveillance to be a nationwide activity. 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 5 The health sector leads awareness activities, with contributions from other relevant sectors (agriculture, livestock, irrigation, WASH, education, information and defence) for the general public and health professionals at the national level. Agriculture sector contributed by organizing field trips to enhance understanding of AMR. For AAW, operationalize the technical group formed and enhance the engagement of sectors such as plant, environment and defence in various activities. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 1 A mechanism for the co-sharing resources is yet to be developed. Map the resources available to develop operational plans and establish a mechanism for the co-sharing of resources for AMR initiatives. 84 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance 2016 2018 Fig 19: Situational analysis of progress on AMR prevention and containment in Myanmar, 2016–2018 Good practice The coordination among all stakeholders exhibited during the celebration of the AAW is remarkable. The multisectoral governance and coordination mechanisms are exemplary. Each sector has a clearly defined role while conducting activities under the able guidance and leadership of the national government. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 85 Nepal Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 2 2 A draft NAP-AMR is under review for alignment with the GAP- AMR. It will include operational plans and detail activities for all sectors, that is human, animal, food and environment. Expedite the endorsement of the NAP-AMR by the government on priority. 2. Raising awareness 2.1 Awareness campaigns for the public 2 2 Some government-led activities, including AAW, are conducted in parts of the country to raise awareness of AMR. The Member States will adapt the internationally available messages on AMR to suit the country’s context. To assess the baseline understanding of AMR concepts among the public, it is recommended that a knowledge, attitude and practice survey be conducted, and the gaps identified be addressed by formulating strategies in coordination with the National Health Education and Information Centre. 2.2 Education and training strategies for professionals 2 1 There is no policy/ strategy for the training of health professionals. The curriculum of medical universities is under revision to focus on AMR. It is imperative to prepare training material with specific information on AMR for induction training and continuous professional development courses for professionals in the human health, animal and plant health, and environment sectors . Procedures for the revision of curriculum for all health professionals to include information on AMR stewardship must be expedited. 3. National AMR surveillance system 3.1 National human AMR surveillance 3 4 Standardized human AMR surveillance has been initiated at a limited number of sites. Data management needs to be strengthened to ensure timeliness and completeness, and regular analysis. Human AMR surveillance sites should be expanded so as to be representative of the entire country. Conduct structured training of laboratory experts and data managers, and establish strong coordination between programme managers and laboratory surveillance to support human ARM surveillance. 86 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 3.2 Strengthening of national laboratory network 3 3 The national public health laboratory has been identified as the national reference laboratory. A quality assured laboratory network of both public and private sector facilities has been established at limited sites. There is a need to build technical expertise in laboratory diagnostics, strengthen laboratory infrastructure, develop standardized protocols/guidelines and augment data management capacity. 3.3 Early warning systems 2 1 There is no system in place for AMR bacteria. Establishing an EWS requires capacity-building of the national reference laboratory in molecular detection and developing a repository of organisms. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 2 1 There is no national policy, plan or regulations for the use and sale of antimicrobials. A national list of essential drugs is available and standard treatment protocols are followed for some diseases (TB, malaria, HIV, leprosy). A national antibiotic policy needs to be framed and treatment guidelines developed for the prescription of antimicrobials at different levels of health facilities. 4.2 NRA/ DRA 3 4 An NRA/DRA system has been set up for oversight, but it is not fully functional. Ensure the availability of adequate financial resources and trained manpower at the NRA so that it performs optimally and supports the implementation of NAP-AMR. 4.3 Surveillance of AMU and sale among humans 3 1 There are no guidelines for surveillance of the use and/or sale of antimicrobials. To establish AMU surveillance in the human health sector, it is crucial to develop a national AMU monitoring system with technical assistance from the development partners. 4.4 Regulation of finished antibiotic products and APIs 2 2 Regulation is limited. However, strategic planning is under way for capacity-building and appropriate budgeting. Strengthen the NRA’s capacity for dossier review and antibiotic registration, conducting post- market survey for quality assurance of antibiotics, regulating finished products and APIs and prohibiting OTC sale of antibiotics. 4.5 Regulation of pharmacies regarding OTC and inappropriate sale of antibiotics and APIs 3 2 Regulation is limited. However, strategic planning is under way for capacity-building and appropriate budgeting. Same as 4.4 87 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 2 1 There is no national AMR stewardship policy, or operational plan available or approved. A prerequisite to strengthen the AMSP is to update the essential drug list and list of drugs included in social health insurance programmes. It is imperative to incorporate AMR stewardship concepts in training courses specifically for health professionals and implement AMSP on priority in hospital management. 5.2 IPC programme in health-care setting 1 1 There are no national IPC policy, guidelines and action plans to mandate IPC in health- care settings. Infection control committees have been set up in all hospitals, but standard treatment guidelines are not available. To formulate a national policy, it is essential to develop standard treatment protocols for nationwide implementation, strengthen infrastructure and establish IPC committeein health facilities. 5.3 National HAI and related AMR surveillance 1 1 There is no policy in this sphere. The national plan and guidelines to mandate hospitals for HAI surveillance are limited. Few public and private hospitals have HAI surveillance, and there is no mechanism for centralized data reporting. To assess magnitude of HAI in the country and address barriers in reporting, HAI surveillance coordinated by the national infection control committee should be established. 5.4 Sanitation and hygiene 2 4 A policy on improving sanitation and hygiene is implemented on a large scale, with campaigns being held regularly. The Member States should strengthen the sanitation and hygiene campaign and routine immunization activities across the nation. 5.5 Vaccination NA 2 The PCV 10 and HiB vaccines are part of the national immunization programme, while the introduction of the typhoid vaccine is in the pilot phase. Consider the development of a vaccination policy in the context of AMR practices. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 1 1 The NAP plans to foster R&D on AMR but no technical committee or working group has been formed to support it. Also, there are no dedicated funds to promote innovation. Ensure the availability of funds to conduct targeted research focused on AMR. 88 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for the control and registration of use in animals 2 1 There is no national policy or plan to reduce AMU in veterinary/ fisheries sector. A regulatory framework has been developed for the control and registration of use in the animal sector, but it has not been implemented. It is imperative to develop standardized protocols and methodology for laboratory diagnostics, build on the available infrastructure and ensure data management. The Member States should prepare protocols to monitor the use and sale of antimicrobials in the animal sector and ensure timely sharing of data with national and international stakeholders. Engage the National Veterinary Council in developing a policy on communication strategies and disseminating information in the veterinary sector using the mass media. Develop surveillance guidelines and build the capacity of laboratories in the veterinary sector, and ensure biosecurity measures. 7.2 National surveillance of AMR, and use and sales of antimicrobials in veterinary sector 2 AMR 1; AMU 2 There are no policy/ guidelines for AMR surveillance, and the use and sales of antimicrobials in the veterinary sector at the national level. The central veterinary laboratory has been identified as the coordinating laboratory for AMR surveillance. The information shared with the OIE global database on the use of antimicrobials in the animal sector is primarily based on the supplies/sales data on the import of antibiotics. Same as 7.1 7.3 Biosecurity (IPC) in animal sector 1 2 Biosecurity strategies and guidelines have been developed. Training is conducted to build the capacity of farmers, and owners of commercial poultry farms and hatcheries as per the directives of the ministry of Agriculture. Same as 7.1 89 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 7.4 AMR awareness generation and education in animal sector 1 1 There is no policy and no systematic effort has been made to raise AMR awareness. Awareness activities are conducted by different stakeholders but no concerted effort has been made. Same as 7.1 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 There is no specific regulation/ national policy to control the release of antibiotic residue and AMR into the environment. Nor is there any regulation or policy for a water management system. Enhance the engagement of the environment sector and link existing policies with AMR-related issues. The involvement of the environment sector is critical to establish national surveillance of AR and AMR in wastewater from all relevant sectors. There is strong need to develop a policy to control antibiotic residue in food and the environment. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1 There is no national policy for surveillance of AR/AMR in waste and the environment. An ad hoc study is being conducted for antibiotic levels in fisheries. Same as 7.5 7.7 AMR awareness generation and education in environmental sector NA 1 The environment sector does not have a specific strategy on the generation of awareness and education on AMR. It is not included in AMR-related policy committees. Same as 7.5 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 2 A national AMR coordination committee has been established, but needs to be modified, considering the federal context and administrative restructuring, to make it more inclusive, with all relevant stakeholders . The composition of multisectoral committee established for overarching AMR coordination must be reviewed so that it has nationwide representation, in the context of administrative restructuring in the country. Ensure the inclusion and engagement of stakeholders from all relevant sectors. 90 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/comments Recommendations 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 2 The NAP-AMR is under review for alignment with GAP- AMR and representativeness in the federal context. A national AMR multisectoral committee has been proposed with representation from the ministries of food, environment, education, information technology and finance, and the National Health Research Council, civil society and private sector. Same as 8.1 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 1 There is no policy/ mechanism/ platform for the sharing of AMU data among the relevant sectors. No information on AMU is available from the human health sector for want of guidelines. Limited information related to the animal sector is gathered from procurement data. There is no sharing mechanism. The Member States should streamline data flow and develop platforms for the regular sharing of information across all sectors to establish the transmission pathways of AMR. There is a need to outline a strategy for data management at the national level, both for AMU and AMR surveillance, and for sharing with all national and international stakeholders to enable evidence- based decision-making at all levels. 8.4 A platform and/ or mechanism for sharing AMR surveillance data from all relevant sectors NA 2 There is a platform for the sharing of data on animal health with the national reference laboratory for human health. Same as 8.3 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 3 AAW is celebrated jointly by the human and animal health sectors in collaboration with FAO and WHO. Most activities are conducted in Kathmandu. Build synergies among all relevant sectors for a nationally coordinated AAW and plan activities spread across the entire calendar year. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 1 There are no provisions for sharing resources for AMR initiatives across ministries. The MoH allocates funds for AMR activities from its annual budget. Stronger advocacy is needed with policy-makers for the allocation of dedicated funds for AMR activities. Explore the feasibility of resource-sharing across the relevant sectors. 91 2016 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance Fig 20: Situational analysis of progress in AMR prevention and containment in Nepal, 2016–2018 Good practice The PCV-10 vaccine was introduced in routine immunization in 2015. The coverage of PCV primary and secondary doses reached 90% and 88%, respectively, and that of the booster/third dose reached 80% in 2017. The Hib vaccine was introduced as part of a pentavalent vaccine in 2009, and the coverage of pentavalent 3 was 90% in 2017 (WHO-UNICEF estimates). The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 92 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Sri Lanka Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and overnance 1.1 NAP in line with GAP-AMR/ governance issue 3 4 The NAP has been developed in line with the GAP-AMR and makes provision for the National Advisory Committee on AMR and NAP implementation strengthening team. An operational plan characterized by a multisectoral approach is being rolled out and scaled up, covering defined activities with their respective budgets. To strengthen the implementation of NAP-AMR, ensure that it is endorsed by all ministries concerned, including environment and food safety, along with the human and animal health sectors. Develop a regular monitoring framework for the assessment of the impact of AMR surveillance systems. 2. Raising awareness 2.1 Awareness campaigns for the public 2 4 A nationwide, government-led antibiotic awareness campaign targeting the public and professionals was organized by the health sector. Baseline data on AMR awareness among the public has been collated through a study conducted in the community regarding knowledge, attitudes and practices. Continue with activities for the generation of awareness among the public and evaluate the effectiveness of the campaigns with a focus on behavioural change. Consider external evaluation for the assessment of impact. The Member States may conduct studies among farmers to identify the existing practices and customize communication strategies accordingly. 2.2 Education and training strategies for professionals 1 3 The topic of AMR has been included as a core component of the service training programmes of all health-care professionals (doctors, pharmacists, nurses, veterinarians) and incorporated in the in-service continuing professional development programmes for veterinary surgeons and extension officers. For in-service laboratory technicians, an external quality assurance programme based on AMR detection has been developed. The inclusion of AMR in the medical and school curriculums has been proposed. Education and training programmes should continue to focus on building AMR concepts with regular updates. Develop strategies to monitor and evaluate the quality of workshops/ courses/ training conducted for laboratory technicians, nurses and other paramedical professionals and experts. 93 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3. National AMR surveillance system 3.1 National human AMR surveillance 3 4 The surveillance programme is designed in line with the Global Antimicrobial Surveillance System. The use of WHONET has been introduced for surveillance and data collection, but there is no contribution of data to GLASS. Capacity-building programmes to monitor AMR trends accurately are under way. Deputy Dir. Gen. of Health Services (LS) is recognized as the National Coordinating Centre. Continue with the ongoing activities related to human AMR surveillance and document progress in an annual report. Build capacity for data management, expand the use of WHONET and contribute regularly to GLASS. 3.2 Strengthening of national laboratory network 2 5 A nationwide laboratory network has been established. It comprises 25 laboratories in the private and public sectors, the Medical Research Institute serving as the national reference laboratory. The laboratory network has adopted the CLSI as the performance standard and participates in the national external assurance programme. It has recently enrolled in GLASS and is likely to initiate data- sharing soon. Strengthen laboratory-supported human AMR surveillance, build technical expertise and progress towards accreditation standards in laboratory performance. 3.3 Early warning systems 1 1 No EWS has been established. To establish an EWS, enhance the capacity of the laboratory network for molecular detection and explore the use of advanced software for data analysis and alert generation. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 2 2 A national AMSP has been planned and is being developmed. National guidelines have been framed on empiric antimicrobial therapy and the DGHS has issued a circular on the restricted use of antibiotics. ‘Red Light Antibiotics' are available guidance documents. Implement the national AMSP, adopt the WHO essential medicine list and build capacities to develop curriculum and conduct specialized trainings on AMSP. Participate in Regional collaboration and the exchange of information on antimicrobials. 94 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 4.2 NRA/DRA 2 4 The NRA is fully operational. Tools for quality assurance and the registration of antibiotics are in place. Inspections are conducted, but the capacity for the enforcement of policies and regulations is limited. Promote regulatory cooperation on the import of medical products and AMR in SEARN; ensure quality assurance of the laboratory network and develop an API analysis system. 4.3 Surveillance of AMU and sale among humans 1 3 Monitoring of the sale of antimicrobials at the national level has not been implemented. Monitoring of AMU is limited to a few facilities that are not representative. A national antibiotic consumption survey covering all provinces is under way. Develop a national AMR containment policy and establish a national AMU monitoring system to control the use of antimicrobials in humans. Expedite the completion of the national survey on antibiotic consumption. 4.4 Regulation of finished antibiotic products and APIs 2 3 There is a regulatory authority and a system for oversight with a limited functional capability. APIs of registered local products are permitted to be imported through a licence system. Provide adequate human and financial resources to strengthen the regulatory capacity of the NRA to conduct pre- and post- marketing surveillance and enforce regulations on finished products and APIs. 4.5 Regulation of pharmacies regarding OTC and inappropriate sale of antibiotics and APIs 2 4 There is a regulatory authority and a system. Inspection is implemented, but the capacity for the enforcement of regulation is limited. OTC dispensing of medicines is prohibited. To regulate the inappropriate sale of antibiotics and APIs, consider advanced IT solutions to manage the referral, prescription and drug dispensing systems. 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 1 2 There is a national IPC/AMR policy and an operational plan. However the SOps are weak, and guidelines and protocols, which need to be updated, are not available at all hospitals. Red light Antimicrobial prescriptions defined under AMSP and is included in guidance document. Ensure the availability of SOPs and guidelines, and strengthen the laboratory capacity at health- care facilities to support the national AMSP. 5.2 IPC programme in health-care setting (HCS) 3 4 A national advisory committee on IPC has been set up and national guidelines on IPC based on the WHO core component are being framed. An infection control manual and local guidelines are used by the infection control committees in hospitals. Provide adequate human and financial resources for the IPC programme in health- care settings and evaluate the implementation status periodically. 95 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5.3 National HAI and related AMR surveillance 2 4 Many public and private facilities are conducting HAI surveillance and centralized data on HAI from several hospitals are available, but the capacity for detection and data analysis is limited. Conduct HAI surveillance in tandem with human AMR/AMU surveillance in health-care facilities. 5.4 Sanitation and hygiene 4 4 The policy on improving sanitation and hygiene is implemented on a large scale, with regular campaigns. There are data on safe water supply and sanitation services, and access to them is medium. Promote measures to enhance compliance with sanitation and hygiene standards and collect baseline data to confirm the status of safe water supply across the country. 5. Infection prevention control and AMR stewardship programme 5.5 Vaccination NA 3 Two types of pneumococcal vaccines (PCV 10 & 13 and PPSV23) are available in the private sector, but not included in the EPI schedule. Typhoid vaccines are given to food handlers and to the general public during outbreaks. The vaccines available are Vi polysaccharide vaccine and Ty21 capsule for oral administration. The inclusion of vaccines in the EPI schedule is based on periodic review of disease burden. Advocate for the inclusion of PCV in routine immunization and monitor trends of AMR to update disease burden estimates for evidence-based introduction of vaccines. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 1 2 Policies have been framed and it is proposed that the existing structure will foster research and innovation on AMR in both the human and animal sectors. Plan targeted research projects to provide baseline data on AMR/ AMU in the human, animal and environment sectors to support implementation and M&E of NAP- AMR. There is a need to explore and approach national and international funding agencies for sustainable funds to conduct research activities. 96 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for the control and registration of use in animals 3 4 A policy has been framed and a plan implemented. There is some capacity for monitoring, but the capacity fo enforcement is limited. Add into a national AMR containment policy a support national surveillance of AMU and sales, in the veterinary sector. It is important to prepare national guidelines for the collection, analysis and timely sharing of data on AMR and AMU with national and international stakeholders across all relevant sectors. 7.2 National surveillance of AMR, and use and sale of antimicrobials in veterinary sector 1 AMU -2; AMR -3 There is limited capacity for surveillance of the sale and use of antimicrobials in the animal sector. Aggregated data of active ingredients based on import data, licence data as all registration data are shared with the OIE. The Member State should conduct systematic assessment of the AMR surveillance system, build laboratory capacity and ensure the availability of funds to continue AMR containment initiatives in the veterinary sector. 7.3 Biosecurity (IPC) in animal sector 2 3 Training on AMR and alternative biosecurity measures has been started for professionals in the animal sector. The existing policies, strategies and guidelines focus primarily on poultry farming. To strengthen biosecurity measures, harmonize guidelines across the animal sector, introduce an audit system that is applicable to different kinds of livestock and evaluate the impact of generating awareness in the veterinary sector. 7.4 AMR awareness generation and education in animal sector 1 3 Awareness programmes have been developed and undergraduate curriculums revised to include AMR. AMR has also been incorporated in in- service/ continuing professional development programmes for veterinary surgeons, para- professionals (diploma-holders) and extension officers. Create awareness among animal handlers on AMU and AMR using mass media channels and social media platforms. 97 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 2 A national policy to reduce antimicrobial waste generation has been formulated and approved. Regulations are in place to control AR emissions from antimicrobial manufacturers, hospitals and waste-water treatment plants. Environmental protection policy (licence) is renewed annually and environmental impact assessment is mandatory for new projects. Develop guidelines to enhance the engagement of the environment sector and implement the national policy on waste management. It is crucial to establish surveillance of AR and AMR in waste water from the human and animal sectors. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1 Environment is not included in the NAP-AMR. Though not specific to AMR, a fully functional programme on waste-water management exists. Same as 7.5 7.7 AMR awareness generation and education in environmental sector NA 1 The environment sector is not involved in AMR-specific activities. Environmental awareness programmes should include messages on AMR. There is a need to link AMR with the existing environment protection licensing system in the country. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 2 Overarching AMR coordination has been ensured by establishing a national advisory committee on AMR and the NAP implementation strengthening team on the basis of a multisectoral approach. Strengthen the coordination mechanism between all relevant sectors with enhanced engagement and involvement of the environment, food safety, education, aquaculture, and animal and human health sectors. 98 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 2 The NAP-AMR includes various sectors, though the level of engagement of each sector is different. The various sectors involved in NAP-AMR are human health sector including pharmaceutical , dental, professional college associations and medical education, agriculture and livestock including veterinary council, plant health, food production and food safety, private sector and some aspects of WASH. Same as 8.1 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 3 Information pertaining to AMU monitoring is available from the human health and animal health sectors, which share data intermittently. The national steering committee helps in the sharing of information on AMU among the human health, animal health and plant sectors. However, there is no formal mechanism of data-sharing between all the relevant sectors. Establish coordinated mechanisms for AMR/AMU surveillance and implement AMR containment across relevant sectors. Provide a platform for the sharing of monitoring data regularly with national and international stakeholders across all sectors to ensure evidence- based policy decisions. 8.4 A platform and/ or mechanism for sharing of AMR surveillance data from all relevant sectors NA 2 AMR surveillance in human health sector has been streamlined. Mechanisms have been developed for AMR surveillance in the animal health sector, but not fully implement. In the environmental sector, AMR surveillance is in the initial stages of establishment.There is no mechanism for the sharing of AMR surveillance data among different sectors. Same as 8.3 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 2 AAW activities are led by the human health sector, with the involvement of the animal health, food safety and environment sectors. However, national level coordination is weak. Carry out impact assessment of activities for the generation of awareness conducted with the involvement of and contributions from all relevant sectors. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 3 There is no established mechanism for the co-sharing of resources for AMR initiatives in the country. Identify resources and establish a mechanism for the co-sharing of resources for AMR initiatives. 99 2016 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance Fig 21: Situational analysis of progress in AMR prevention and containment in Sri Lanka, 2016–2018 Good practice Of all the good practices in the country, the foremost is the National Medicinal Registration Authority, which ensures that all medicines, medical devices, etc. are safe, efficacious and of acceptable quality. Another good practice is the drug registration policy, which calls for the submission of the availability of stocks and information pertaining to the quantity of antimicrobials imported for the yearly renewal of the import licence. In addition, a well-established system for the distribution of all medical supplies ensures timely and regular availability of medicines in all hospitals in the public sector. The focus on the environmental sector is commendable. Environmental impact assessment is mandatory for new projects as well as for the annual renewal of the environmental protection licence (a regulatory/legal tool under the provision of the national Environmental Act (license scheme). Though not specific to AMR, there is a fully functional programme on waste water management that may serve as a model for cross-learning for other countries in the Region. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 100 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Thailand Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 3 5 An operational plan is being rolled out and scaled up. It outlines defined activities with their respective budgets. However, implementation and sustained coverage are challenges. For sustainable coverage and successful implementation of NAP-AMR, it is crucial to build an M&E framework. Ensure that the NAP-AMR prepared by health ministry is fully endorsed by all relevant stakeholders. 2. Raising awareness 2.1 Awareness campaigns for the public 2 4 Nationwide, government-led campaigns are held to raise awareness of antibiotics among the public and professionals. Adopt a nationally coordinated multisectoral approach for mass awareness. Prepare a national strategy for awareness generation with mechanisms to assess the impact of the awareness generation campaigns on the public. Focus on communication risk analysis to avoid miscommunication, especially in the animal sector. 2.2 Education and training strategies for professionals 3 5 AMR has been incorporated in the pre-service training programmes for all relevant cadres. Regular continuing professional development training is conducted for health professionals. Continue the implementation of the existing education and training strategies for professionals in the human and animal health sectors. 3. National AMR surveillance system 3.1 National human AMR surveillance 3 5 A national AMR surveillance programme is functional to monitor AMR trends accurately and in a timely fashion. It has been contributing data to GLASS since 2017. The National Antimicrobial Resistance Surveillance Centre (NARST) has been functional since 1997. To strengthen human AMR surveillance, increase the number of sites contributing to GLASS, improve the efficacy of the information management system and promote the utilization of the data by policy-makers and health-care providers. 101 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3.2 Strengthening of national laboratory network 4 5 The laboratory network comprises 97 laboratories nationwide from the public and private sectors. The National Institute for Health (NIH) serves as the national reference laboratory. This, as well as a few network laboratories, have ISO151189 certification, which ensures the maintenance of the highest standards of quality. EQA measures are in place and operated by NARST. Research is the core mandate of the NIH and research-related activities are supported by well-established infrastructure, equipment, human resources and budget. Strengthen laboratory-supported AMR surveillance and maintain technical expertise by regular capacity-building. Build international collaboration to provide opportunities for cross- learning by sharing experience, knowledge and technologies. 3.3 Early warning systems 1 2 The systems planned for early warning of emerging AMR are in line with international standards. Pilot projects for EWS have been initiated in a few hospitals (not in place yet) Set up a national committee to establish EWS as per international standards. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 2 3 A national AMSP has been developed. It includes tools to implement and monitor progress and impact. Expedite the finalization of the national antibiotic policy. The policy should cover treatment guidelines, including prescription requirements, and restrictions on sales by private pharmacies. Intensify multidisciplinary capacity-building for AMSP in hospitals. 4.2 NRA/ DRA 2 3 Tools for quality assurance and registration of antibiotics are in place and inspection is implemented, but the capacity for the enforcement of policies and regulation is limited. Promote regulatory cooperation in SEARN on AMR for the import of medical products and regulatory cooperation in the laboratory network. 102 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 4.3 Surveillance of AMU and sale among humans 2 4 Mechanisms are in place for the regular collection of data on antimicrobial sale at the national level. AMU data are collected by a few health-care facilities, but it is not a representative sample. The linking of AMU data analysis with the national laboratory- based AMR surveillance is weak. Develop operational plans to conduct regular surveillance of AMU and sale in the human sector. Complete the antibiotic consumption survey in the human sector and share results to support policy decisions. 4.4 Regulation of finished antibiotic products and APIs 2 4 A regulatory authority and system are in place and inspection is implemented but the capacity for the enforcement of policies and regulation is limited. Strengthen the capacity of the NRA for dossier review and antibiotic registration; conducting post-market surveys for quality assurance, and implementing regulations on finished products and API. 4.5 Regulation of pharmacies regarding OTC sale and inappropriate sale of antibiotics and APIs 2 4 A regulatory authority and system are in place and inspection is implemented, but the capacity for the enforcement of policies and regulation is limited. Promote regulatory cooperation in SEARN on AMR for the import of medical products and regulatory cooperation in the laboratory network. 5. Infection prevention control & AMR stewardship programme 5.1 AMSP in health- care setting 3 4 The national policy and operational plan are weak. SOPs, guidelines and protocols, with limited updates, are available at only some hospitals. Finalize guidelines, monitoring tools and mechanisms for systematic feedback of laboratory findings to physicians. 5.2 IPC programme in health-care setting 2 3 The IPC programme and capacity-building plans have been implemented in select health-care facilities with limited monitoring. A national IPC plan/ policy is under development. Ensure adequate resources, including hospital infrastructure for the isolation of patients upon the detection of AMR. 5.3 National HAI and related AMR surveillance 2 4 The IPC programme and capacity-building plans have been implemented nationwide . Focus on capacity-building of infectious disease experts, nurses and pharmacists to support the surveillance of HAI. 5.4 Sanitation and hygiene 3 4 The policy on improving sanitation and hygiene is implemented on a large scale through regular campaigns. Standardize reporting and collation of data on hand hygiene to strengthen the sanitation and hygiene practices. 103 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5.5 Vaccination NA 3 PCV 13 is not mandatory under the EPI schedule. A cost- benefit analysis is planned for evidence generation and stronger advocacy. Consider the inclusion of PCV in the EPI schedule on the basis of a disease burden assessment and in the context of AMR containment. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 1 4 The NAP outlines a plan to foster R&D and innovation on AMR prevention and containment. Funds have been secured from domestic and international donors. Continue research activities to support the implementation of the NAP-AMR. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for registration and control of use in animals 2 3 Policies and/or regulatory frameworks have been implemented, but there is limited capacity for the monitoring of registration and AMU in the animal sector. Develop collaborative mechanisms among multisectoral stakeholders and ensure adequate resources to implement veterinary legislation and policy for AMR containment in the animal sector. 7.2 National surveillance of AMR and use and sales of antimicrobials in veterinary sector 2 AMU-3 AMR-3 A national surveillance system for the use and sale of antimicrobials in the veterinary sector has been set up. Guidelines on the collection of AMU data need to be developed. Information is shared annually with the OIE on the basis of estimates of sales of antimicrobials. Strengthen the existing AMR surveillance by reviewing guidelines to involve food production, food safety and veterinary R&D. Develop guidelines on AMU data collection in the animal sector, including aquaculture, to establish a national surveillance of the use and sale of antimicrobials. 7.3 Biosecurity (IPC) in animal sector 2 5 The national guidelines have limited reference to biosecurity. They outline disease control, disinfection check and standard farm care for large-scale commercial farms, industries and biosecurity measures for slaughter houses. It is proposed to include AMR in the existing guidelines. Develop guidelines on animal rearing without antibiotics. Enhance awareness and diagnostic support and formulate a registration system for backyard farming. 7.4 AMR awareness generation and education in animal sector 2 4 The curriculum for veterinary training has been revised to include AMR. Awareness generation campaigns with a multisectoral approach and a focus on the animal sector are being conducted. Continue the implementation of the existing education and training strategies for professionals. 104 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 2 There is no national policy on AR and AMR disposal in the environment. However, the release of AR from manufacturing units is well regulated by the existing policies. Develop a regulatory framework to control the release of AR and AMR in the environment. There is a need to address the knowledge gap regarding the cumulative long-term impact of releasing AMR organisms into the environment (both terrestrial and marine systems). 7.6 National surveillance of AR and AMR in wastewater from manufacture and use in the human, animal and fish sectors and disposal by institutions and homes NA 1+ Although there are mechanisms for monitoring the environment, these are not AMR-specific . Same as 7.5 7.7 AMR awareness generation and education in environmental sector NA 2 A policy and targeted communication strategies have been formulated primarily for the management of waste from the pharmaceutical sector. Quality surveillance of surface water is conducted quarterly for coliform count, but it is not related to AMR. Focus on raising AMR awareness, and organize trainings and workshops for professionals in the environment sector. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 4 The One Health approach is followed at all levels of the AMR governance structure, such as the national AMR strategic committee and multisectoral working groups for planning and implementation. Strengthen the overarching AMR coordination mechanism between all relevant sectors and include the plant and agriculture sectors. 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 5 The NAP-AMR includes and engages various sectors, including human health, animal health, agriculture, environment, food safety, food production, WASH, trade and civil society for the containment of AMR. Same as 8.1 105 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 3 Databases of wholesale and production of antimicrobials in the human and animal health sectors are available. The system allows monitoring of AMU data. THAISAC is a platform developed for the sharing of AMU monitoring data between the human and animal health sectors. The animal sector has a mechanism for an AMU data repository (ICT system). However, the contribution from various stakeholders is suboptimal. There is limited involvement of the plant and agriculture sectors in collating AMU data. Establish a platform and/or mechanism for the sharing of AMR and AMU monitoring data from all the relevant sectors. Review AMU in plant and agriculture sectors in the context of the AMR containment policy. 8.4 A platform and/ or mechanism for sharing AMR surveillance data from all relevant sectors NA 2 In the human health sector, a pathogen surveillance system has been functional for the past two decades. AMR surveillance data are available in the animal sector, but not shared regularly across sectors. Information is disseminated during meetings in an ad hoc manner. Same as 8.2 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 5 AAW is nationally coordinated and celebrated with the involvement of the human health, animal health, environment, agriculture and plant sectors, and NGOs. Activities are conducted thorough out the year to promote rational use in the community. Promote the generation of awareness of antimicrobials, sustain collaboration between the human and animal health sectors and include other sectors to sustain activities outside of AAW. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 3 One Health approach is applied to all levels of AMR governance structure such as National AMR strategic committee and working groups with multisectoral planning and implementation. 106 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 2016 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance Fig 22: Situational analysis of progress in AMR prevention and containment in Thailand, 2016–2018 Good practice Several remarkable activities have been undertaken to curb AMR in the human sector. There is a well-defined laboratory network, comprising 97 laboratories and a national reference laboratory, with state-of-the-art diagnostic facilities, standard guidelines, and external quality assurance. The capacity-building activities undertaken are good practices for AMR containment. Another set of activities which deserve special mention relate to the maintenance of very high standards sanitation and hygiene, and water supply, particularly the availability of potable water in health-care facilities. The enforcement of the ban on the irrational use of antimicrobials in the animal sector to promote growth is commendable. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 107 Timor-Leste Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 1. National AMR plan and governance 1.1 NAP in line with GAP-AMR/ governance issue 2 2 The NAP-AMR, which is line with GAP-AMR, includes an operational plan with defined activities and their respective budgets. A national multisectoral AMR committee has been established. To implement the NAP-AMR, it is recommended a national multisectoral committee with adequate resources be established. To ensure political commitment and ownership by the country, it is important to have a NAP-AMR endorsed by the government. 2. Raising awareness 2.1 Awareness campaigns for the public 2 4 Nationwide, government-led awareness campaign are held. These target the public and professionals. Survey conducted to assess the awareness of AMR among the public and IEC material has been developed for the rational use of antimicrobials. Develop methodology to evaluate the impact of the campaigns conducted among the public to raise awareness of AMR. 2.2 Education and training strategies for professionals 1 3 Awareness for health professionals conducted on policy. Guidelines have been developed for AMR- specific education/training for professionals. Formulate a policy and guidelines for the revision of the curriculum and induction training as well as continuous professional development courses on the prudent use of antimicrobials in the human and animal health sectors. 3. National AMR surveillance system 3.1 National human AMR surveillance 1 2 Guidelines have been developed but are not fully implemented. Only limited quality data are available and there are problems related to analysis and representativeness. Strengthen policies and regulations to enforce implementation of the existing guidelines and ensure a robust data analysis system to address the gaps in monitoring and evaluation. 3.2 Strengthening of national laboratory network 1 1 There is no national network. It is essential to build a laboratory network with an identified national reference laboratory, adopt standard diagnostic guidelines, establish quality assurance measures, and build capacity for data management using WHONET. 108 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 3.3 Early warning system 1 1 EWS are not established for AMR bacteria. Set up EWS for the rapid detection of AMR organisms and a database to provide information on AMR risk on a real-time basis, using advanced IT software. 4. Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials; AMR stewardship 1 2 There are plans to develop a national AMSP. There is a need to develop an AMSP. A national antibiotic policy with definite treatment guidelines, including norms for prescription at health facilities, and restrictions on sales at private pharmacies needs to framed. Provide adequate human, financial and technical resources for implementation of antimicrobial stewardship programme . 4.2 NRA/ DRA 1 2 There is an NRA/DRA with a limited capacity. Strategic planning is in place for capacity- building and appropriate budgeting. Promote regulatory cooperation with SEARN on AMR for the import of medical products and regulatory cooperation between laboratories. 4.3 Surveillance of AMU and sales among humans 1 2 A national policy and plan on surveillance of antimicrobials is being formulated. Limited surveillance is conducted in select facilities and national level sales also survey on AMR consumption done. Enable the organizational structure and capacity of the NRA to regulate pharmacies to meet the requirements of the NAP. Also, build the capacity of the NRA for monitoring AMU in humans. 4.4 Regulation of finished antibiotic products and APIs 2 1 There is no official regulation of import, export, production, distribution and use of finished antibiotic products and APIs. It is essential to strengthen the capacity of the NRA for regulating registration, dossier review, and regulating finished antibiotic products and APIs. Develop capacity of NRA and advocacy to implement regulation for antibiotic policy . 4.5 Regulation of pharmacies regarding OTC sale and inappropriate sale of antibiotics and APIs 1 2 There is national drug Policy, which prohibits the sale of antimicrobials without prescription, but implementation is limited. Same as 4.4 109 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 5. Infection prevention control and AMR stewardship programme 5.1 AMSP in health- care setting 1 1 There is no national AMSP or operational plan. Develop a policy and guidelines for the AMSP and strengthen the capacity of laboratories for the surveillance of AMR/AMU in the human health sector. 5.2 IPC programme in health-care setting 1 1 There is no national policy, guidelines or action plans to mandate IPC in health-care settings. It is crucial to establish an IPC committee and strengthen IPC training in health-care facilities. 5.3 National HAI and related AMR surveillance 1 1 No policies limited to national plan and guidelines to mandate hospitals for HAI surveillance. Develop policy/guidelines and build capacity for HAI surveillance and expand across country in a stepwise manner. 5.4 Sanitation and hygiene 2 3 The policy on improving sanitation and hygiene has been implemented on a limited scale. Data on safe water supply and sanitation services exist, but access is low. Focus on expanding the implementation of the WASH programme. 5.5 Vaccination NA 4 PCV was introduced in the routine immunization programme in 2017. There are no plans for including the HiB and typhoid vaccines in the EPI schedule. Consider developing plans for the sustainability of immunization services beyond GAVI, the vaccine alliance. Support and continue the use of PCV. 6. Research and innovation 6.1 R&D and innovation on AMR prevention and containment and research funding 1 1 There are no policies fostering research and innovation on the prevention and containment of AMR. Build capacity and secure funds for research activities to provide baseline information for AMR/ AMU in the relevant sectors to support the implementation of the NAP-AMR. 7. One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animals 1 1 There is no national policy or plan to reduce AMU in the animal and fisheries sectors. Develop a national AMR containment policy and regulatory framework for the control and registration of AMU in the animal sector. Follow up and finalize the draft legislation and policy. Also, develop collaborative mechanisms among multisectoral stakeholders for the containment of AMR in the veterinary sector . 110 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.2 National surveillance of AMR and use and sale of antimicrobials in the veterinary sector 1 AMU-1 AMR-1 There are no activities on the surveillance of AMU and AMR in the veterinary sector. There is a national veterinary laboratory that can handle bacterial isolation, but not for AST. They have SOPs for some bacteria but not all. Establish AMR surveillance in the animal health sector, supported by a quality assured laboratory network and a robust data analysis mechanism with the cooperation of international experts. Tripartite experts should review the existing laboratory capacity to support surveillance. The National Directorate of Veterinary Services has plans to develop policies and guidelines for AMU, and the collection of sales data. 7.3 Biosecurity (IPC) in animal sector 1 1 There are no biosecurity policies, strategies or guidelines. There is a need to develop guidelines, policy and protocols for biosecurity in the animal sector, including backyard farms and commercial establishments. 7.4 AMR awareness generation and education in the animal sector 1 1 Awareness-generation activities are conducted mostly under the MoH with the engagement of the animal health sector. However, there are no messages specifically targeted at animal health professionals or farmers. Consider technical assistance from Tripartite experts to identify the extent of AMR in various sectors and customized approach to be adopted to reduce the risk of AMR. 7.5 A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management therein NA 1 There is no national policy on reducing antimicrobial contamination of the environment. Develop AMR containment policy and regulatory framework to control antimicrobial contamination of the environment and engage the ministries of commerce, industry and environment to initiate AMR surveillance of waste water and solid waste from all relevant sectors. Conduct research to assess baseline data on AR and AMR from different sources. 7.6 National surveillance of AR and AMR in waste water from manufacture and use in human, animal and fish sectors and disposal by institutions and homes NA 1 Weak national policy and guidelines for the surveillance of AR/AMR in waste and the environment. Though the environment sector is included in the national AMR committee and is part of the NAP, no surveillance of AMR contamination of the environment is conducted. Same as 7.5 111 Focus area and indicators Phase, 2016 Phase, 2018 Justification/ comments Recommendations 7.7 AMR awareness generation and education in the environmental sector NA 1 There are no policies or targeted communication strategies on AMR in waste. It is essential to develop guidelines on the safe disposal of waste water and expired drugs in the context of generating awareness of AMR in the environmental sector. 8. Overarching coordination mechanisms for One Health engagement 8.1 Overarching AMR coordination mechanism between all relevant sectors NA 1 The NAP-AMR mandates a multisectoral coordination committee at the national level and a task force to conduct AMR activities. The process of setting up the committee and task force is under way. Expedite the setting up of the coordination committee and task force for building an overarching AMR coordination mechanism among all relevant sectors. Ensure the inclusion and engagement of all relevant sectors, particularly the environment and plant sectors. 8.2 Inclusion and engagement of all relevant sectors in NAP-AMR NA 3 The NAP-AMR includes and engages various sectors, including human health, agriculture, veterinary, food safety and trade, NGOs, WASH and the private sector. Same as above 8.3 A platform and/ or mechanism for sharing of AMU monitoring data from all relevant sectors NA 1 No mechanism has been developed for the sharing of data from all the relevant sectors. Limited data on AMU are available from the human health sector, but none from the animal sector. Develop an integrated mechanism for the sharing of AMR and AMU monitoring data from all relevant sectors, particularly the human and veterinary sectors. Consider a sentinel survey across different sectors, integrated environment with agriculture. 8.4 A platform and/ or mechanism for sharing of AMR surveillance data from all relevant sectors NA 1 The AST in human health supports the diagnostics and treatment methodology. No organized AMR surveillance is conducted in the human health and animal sectosr. There is no mechanism for sharing data among the relevant sectors . Enhance the involvement of and contributions from all relevant sectors for the generation of awareness of AMR. 8.5 AAW is nationally coordinated and celebrated with involvement of and contributions from all relevant sectors NA 3 AAW is nationally coordinated and celebrated with the involvement of the human and animal health sectors and targets the public at large along with professionals in the human health sector. Build synergies among all relevant sectors to organize a nationally coordinated AAW. 8.6 A mechanism for co-sharing of resources for AMR initiatives NA 1 Funds are available for AMR activities, but there is no mechanism for the co-sharing of resources. Identify resources and initiate co- sharing of these for AMR initiatives. 112 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 - 1.00 2.00 3.00 4.00 5.00 Overarching coordination mechanisms for One Health Engagement One health engagement Research and innovation Infection Prevention Control & AMR Stewardship program Rational use of antimicrobials and surveillance of Use/Sale National AMR Surveillance system Awareness raising National AMR plan and Governance 2016 2018 Fig 23: Situational analysis of progress in AMR prevention and containment in Timor-Leste, 2016–2018 Good practice A strong political will and commitment to reverse AMR trends is evident from the progress in raising awareness and ownership by government authorities. One of the unique measures undertaken to strengthen the awareness of the rational use of antimicrobials is the use of specially designed labels to mark all imported antimicrobials. The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation. 113 Annexures

115 Focus area Indicator 2016 2018 Focus area 1: National AMR plan 1.1 NAP in line with GAP Y Y Focus area 2: Raising awareness 2.1 Awareness to public Y Y 2.2 Education and training for professionals Y Y Focus area 3: National AMR surveillance system 3.1 National AMR surveillance (humans) Y Y 3.2 National laboratory network (humans) Y Y 3.3 Early warning system Y Y Focus area 4: Rational use of antimicrobials and surveillance of use/sales (community-based) 4.1 National AMR containment policy; AMSP (humans) Y Y 4.2 NRA/DRA Y Y 4.3 Surveillance of use and sales (humans) Y Y 4.4 Regulation of finished products and APIs Y Y 4.5 Regulation of OTC sales Y Y Focus area 5: IPC and AMSP 5.1 AMSP in health-care settings Y Y 5.2 IPC in health-care settings Y Y 5.3 National HAI surveillance Y Y 5.4 Sanitation and hygiene Y Y 5.5 Vaccination N Y Focus area 6: Research and innovation 6.1 R&D and innovation Y Y Focus area 7: One Health engagement 7.1 National AMR containment policy and regulations (animals) Y Y 7.2 National surveillance for AMR and AMU (animals) Y Y 7.3 Biosecurity in animal sector Y Y 7.4 Awareness and education regarding AMR (animal sector) Y Y 7.5 National AMR containment policy and regulations for controlled release of AR and AMR (environment) N Y 7.6 National surveillance of AR and AMR in waste water N Y 7.7 Awareness and education regarding AMR (environment sector) N Y Annex 1: List of focus areas and indicators assessed 116 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Focus area Indicator 2016 2018 Focus area 8: Overarching coordination mechanisms for One health engagement 8.1 Overarching coordination mechanisms N Y 8.2 Inclusion and engagement of relevant sector N Y 8.3 Platform for sharing AMU data N Y 8.4 Platform for sharing AMR data N Y 8.5 Nationally coordinated AAW N Y 8.6 Co-sharing of resources for AMR initiatives N Y 117 Annex 2: Situation analysis Tool 2018 (WHO Regional Office for South-East Asia Region) Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 1. National AMR Action Plan N AP In li ne w ith G AP -A M R N o Ac tio n P la n or n o na tio na l m ul tis ec to ra l co m m itt ee o r AM R c om m itt ee es ta bl is he d bu t in vo lv in g on e m in is tr y AM R w or ki ng g ro up es ta bl is he d an d N at io na l a ct io n pl an un de rw ay G AP -a lig ne d Ac tio n pl an * in cl ud in g op er at io na l p la n w ith d efi ne d ac tiv iti es a nd re sp ec tiv e bu dg et a va ila bl e Ac tio n pl an in cl ud es op er at io na l pl an b ei ng ro lle d ou t & sc al ed u p w ith d efi ne d ac tiv iti es a nd re sp ec tiv e bu dg et Ac tio n pl an in cl ud es op er at io na l p la n be in g ro lle d ou t & s ca le d up w ith de fin ed a ct iv iti es a nd re sp ec tiv e bu dg et 2. Awareness raising Aw ar en es s ca m pa ig ns to th e pu bl ic G ov er nm en t no t i nv ol ve d in aw ar en es s- ra is in g ac tiv iti es on a nt ib io tic re si st an ce So m e go ve rn m en t- le d ac tiv iti es in pa rt s of th e co un tr y to r ai se a w ar en es s ab ou t A M R a nd ac tio ns to a dd re ss it N at io nw id e, go ve rn m en t- le d an tib io tic aw ar en es s ca m pa ig n ta rg et in g th e ge ne ra l pu bl ic O R pr of es si on al s* * N at io nw id e, go ve rn m en t- le d an tib io tic aw ar en es s ca m pa ig n ta rg et in g pu bl ic A N D pr of es si on al s P ro gr am h as a st ra te gy to c ha ng e be ha vi ou r an d ca n m ea su re im pa ct of th e pr og ra m m e in p ub lic a nd pr of es si on al s Ed uc at io n an d tr ai ni ng st ra te gi es fo r pr of es si on al s N o po lic y or st ra te gy R el ev an t p ol ic ie s de ve lo pe d bu t a d- ho c tr ai ni ng c ou rs es in s om e di sc ip lin es AM R in s om e pr e se rv ic e tr ai ni ng a nd /o r so m e sp ec ia l co ur se s O R Co nt in uo us pr of es si on al de ve lo pm en t an d re gu la r au di t o f l ea rn in g AM R in s om e pr e se rv ic e tr ai ni ng a nd / or s om e sp ec ia l co ur se s AN D Co nt in uo us pr of es si on al de ve lo pm en t an d re gu la r au di t o f le ar ni ng AM R in co rp or at ed in to p re s er vi ce tr ai ni ng fo r al l re le va nt c ad re s. R eg ul ar c on tin ui ng pr of es si on al de ve lo pm en t 118 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 3. National AMR surveillance system N at io na l hu m an A M R su rv ei lla nc e N o ca pa ci ty fo r AM R la bo ra to ry an d/ or li m ite d re po rt in g; o r no s ur ve ill an ce gu id el in es G ui de lin es de ve lo pe d bu t n ot fu lly im pl em en te d – lim ite d qu al ity d at a an d an al ys is a nd / re pr es en ta tiv en es s St an da rd iz ed na tio na l A M R su rv ei lla nc e in p la ce a nd re pr es en ta tiv e of c ou nt ry b ut lim ite d nu m be r of o p. s ite s Su rv ei lla nc e in p la ce a nd fu nc tio na l to m on ito r AM R tr en ds ac cu ra te ly an d tim el y bu t n o co nt ri bu tin g da ta to G LA SS * N at io na l A M R su rv ei lla nc e re gu la rl y as se ss ed an d ad ju st ed ; a nd co nt ri bu tin g to G LA SS N at io na l La bo ra to ry N et w or k st re ng th en in g N o na tio na l ne tw or k de ve lo pe d A na tio na l n et w or k w ith te st in g ac co rd in g to th e in te rn at io na l st an da rd s is pl an ne d N at . R ef . L ab id en tifi ed a nd qu al ity a ss ur ed la bo ra to ry ne tw or ks de ve lo pe d on ly a t fe w su rv ei lla nc e si te s A na tio na l ne tw or k of EQ A he al th la bo ra to ri es de ve lo pe d in m os t / AL L su rv ei lla nc e si te s La b ne tw or k es ta bl is he d, E Q A m ea su re s in p la ce , an d de m on st ra te d ca pa ci ty o f r ef er en ce la b fo r re se ar ch Ea rl y w ar ni ng sy st em s N o sy st em in p la ce o r pl an ne d Sy st em p la nn ed , in k ee pi ng w ith in te rn at io na l st an da rd s Sy st em is im pl em en te d in pi lo t m od e, o r if im pl em en te d on a n at io na l sc al e ei th er n ot fu lly fu nc tio na l (n ot s en si tiv e to r ep or ta bl e ev en ts ) D em on st ra te d fu nc tio na l ca pa ci ty : d at a ce nt ra lis ed an d an al ys ed w ith r ep or ts D em on st ra te d fu nc tio na l c ap ac ity an d pr oo f o f re sp on se fr om de te ct io n 119 Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 4. Rational use of antimicrobials and surveillance of use/sale (community-based) A na tio na l A M R co nt ai nm en t po lic y fo r co nt ro l of h um an u se o f an tim ic ro bi al s; A M R St ew ar ds hi p ( AM S) N o/ w ea k na tio na l p ol ic y & p la n, r eg ul at io ns fo r an tim ic ro bi al u se a nd av ai la bi lit y N at io na l A M S P ro gr am m e (A M SP ) pl an ne d an d un de r de ve lo pm en t N at io na l A M S P ro gr am m e (A M SP ) is d ev el op ed In cl ud in g to ol s to im pl em en t an d m on ito r AM S pr og re ss & im pa ct AM SP im pl em en te d by re le va nt in st itu tio ns . R eg ul at io ns fo r an tim ic ro bi al u se a nd av ai la bi lit y im pl em en te d in li m ite d ca pa ci ty A na tio na l A M SP fo r co nt ro l o f h um an u se o f an tim ic ro bi al s im pl em en te d an d en fo rc ed > 2 ye ar s N at io na l R eg ul at or y Au th or iti es (N R A) or D ru g R eg ul at or y Au th or iti es (D R A) N o of fic ia l N R A/ D R A or e xi st in g w ith li m ite d ca pa ci ty N R A/ D R A w ith li m ite d ca pa ci ty b ut s tr at eg ic pl an ni ng in p la ce fo r ca pa ci ty b ui ld in g a nd ap pr op ri at e bu dg et in g N R A/ D R A sy st em se t u p fo r ov er si gh t bu t n ot fu lly fu nc tio na l To ol s fo r qu al ity as su ra nc e & r eg is tr at io n of a nt ib io tic s in p la ce a nd in sp ec tio n im pl em en te d bu t l im ite d ca pa ci ty fo r en fo rc em en t o f p ol ic ie s an d re gu la tio n Co m pe te nt a nd fu nc tio na l N R A/ D R A w ith c ap ac ity to en su ri ng /e nf or ci ng a nt ib io tic qu al ity s ta nd ar ds a nd ta ki ng m ea su re s ag ai ns t su bs ta nd ar d pr od uc ts a nd In sp ec tin g ph ar m ac ie s Su rv ei lla nc e of an tim ic ro bi al u se (A M U ) a nd s al es i n hu m an s N o gu id el in es fo r su rv ei lla nc e of u se an d/ or s al es o f an tim ic ro bi al s N at io na l p ol ic y & p la n on s ur ve ill an ce o f us e of a nt im ic ro bi al s un de r de ve lo pm en t o r de ve lo pe d & a pp ro ve d bu t n ot im pl em en te d (s ur ve ill an ce in in di vi du al fa ci lit ie s an d na tio na l l ev el s al es ) M on ito ri ng s al es of a nt im ic ro bi al s at n at io na l l ev el no t i m pl em en te d. M on ito ri ng o f u se lim ite d to fe w fa ci lit ie s th at a re n ot re pr es en ta tiv e an d ir re gu la rl y O n a re gu la r ba si s (e ve ry ye ar /t w o- ye ar s) s al es da ta a t n at io na l l ev el a re co lle ct ed . U se d at a in in di vi du al he al th -c ar e fa ci lit ie s ar e co lle ct ed fr om a s m al l & no t r ep re se nt at iv e sa m pl e. N o es ta bl is he d an al ys is w ith n at io na l A M R la b- ba se d su rv ei lla nc e O n a re gu la r ba si s (e ve ry ye ar /t w o- ye ar s) s al es d at a at na tio na l l ev el a re c ol le ct ed an d AM U s ur ve ys a re c on du ct ed in a r ep re se nt at iv e sa m pl e of fa ci lit ie s & tr an sl at ed in to a ct io ns . A nd li nk s w ith na tio na l A M R s ur ve ill an ce da ta a na ly se d an d re po rt ed R eg ul at io n of fin is he d an tib io tic pr od uc ts a nd a ct iv e ph ar m ac eu tic al in gr ed ie nt s (A P Is ) N o of fic ia l r eg ul at io n on im po rt , e xp or t, pr od uc tio n, d is tr ib ut io n an d us e of fi ni sh ed an tib io tic p ro du ct s an d AP Is o r ex is tin g w ith lim ite d ca pa ci ty R eg ul at io n w ith li m ite d ca pa ci ty b ut s tr at eg ic pl an ni ng in p la ce fo r ca pa ci ty b ui ld in g an d ap pr op ri at e bu dg et in g R eg ul at or y au th or ity an d sy st em s et u p fo r ov er si gh t w ith a lim ite d fu nc tio na l ca pa bi lit y R eg ul at or y au th or ity an d sy st em in p la ce a nd in sp ec tio n im pl em en te d bu t l im ite d ca pa ci ty fo r en fo rc em en t o f p ol ic ie s an d re gu la tio n R eg ul at or y au th or ity a nd sy st em in p la ce a nd a re fu lly an d ef fe ct iv el y im pl em en te d R eg ul at io n of ph ar m ac ie s on o ve r th e co un te r sa le a nd in ap pr op ri at e sa le o f an tib io tic s an d AP Is N o of fic ia l r eg ul at io n on ov er th e co un te r sa le an d in ap pr op ri at e sa le of a nt ib io tic s an d AP Is R eg ul at io n w ith li m ite d ca pa ci ty b ut s tr at eg ic pl an ni ng in p la ce fo r ca pa ci ty b ui ld in g an d ap pr op ri at e bu dg et in g R eg ul at or y au th or ity an d sy st em s et u p fo r ov er si gh t w ith a lim ite d fu nc tio na l ca pa bi lit y R eg ul at or y au th or ity an d sy st em in p la ce a nd in sp ec tio n im pl em en te d bu t l im ite d ca pa ci ty fo r en fo rc em en t o f r eg ul at io n R eg ul at or y au th or ity a nd sy st em in p la ce a nd a re fu lly an d ef fe ct iv el y im pl em en te d 120 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 5. Infection prevention control & AMR stewardship programme AM R st ew ar ds hi p pr og ra m in H ea lt h- ca re se tt in g N o na tio na l A M R st ew ar ds hi p po lic y, or o pe ra tio na l p la n is av ai la bl e or a pp ro ve d A na tio na l I P C/ AM R po lic y, o r op er at io na l pl an , i s av ai la bl e bu t w ea k SO P s, g ui de lin es an d pr ot oc ol s no t av ai la bl e to a ll ho sp ita ls (li m ite d up da te s) N at io na l I P C/ AM R p la n- al ig ne d IP C/ AM R p la ns im pl em en te d in li m ite d nu m be r of H CS N at . I P C/ AM R p la n- al ig ne d IP C/ AM R p la ns ar e im pl em en te d in a bo ut al l H CS IP C/ AM R m ea su re s an d th e ef fe ct iv en es s is w id el y im pl em en te d an d re gu la rl y ev al ua te d an d sh ar ed IP C pr og ra m in he al th -c ar e se tt in g (H CS ) N o na tio na l I P C po lic y, gu id el in es o r ac tio n pl an s to m an da te IP C in H CS A na tio na l c ap ac ity bu ild in g pr og ra m m e, or o pe ra tio na l p la n, is d ev el op ed ; S O P s, gu id el in es a nd p ro to co ls de ve lo pe d an d av ai la bl e B ut n ot im pl em en te d IP C pr og ra m m e an d ca pa ci ty b ui ld in g pl an s im pl em en te d in s el ec te d H CS IP C pr og ra m a nd ca pa ci ty b ui ld in g pl an s im pl em en te d na tio nw id e IP C ca pa ci ty b ui ld in g an d pr og ra m m e ef fe ct iv en es s ar e re gu la rl y ev al ua te d an d sh ar ed N at io na l H AI a nd re la te d AM R su rv ei lla nc e N o po lic ie s, li m ite d na tio na l p la n an d gu id el in es to m an da te ho sp ita ls fo r H AI su rv ei lla nc e Fe w p ub lic a nd p ri va te fa ci lit ie s ha ve H AI su rv ei lla nc e bu t d at a no t ce nt ra liz ed a t n at io na l le ve l Fe w p ub lic a nd p ri va te fa ci lit ie s ha ve H AI su rv ei lla nc e an d sh ar e da ta w ith n at io na l l ev el Ce nt ra lis ed d at a on H AI fr om s ev er al h os pi ta ls b ut w ith li m ite d da ta a na ly si s an d de te ct io n ca pa ci ty M on ito ri ng a nd r es po ns e fr am ew or ks e st ab lis he d to id en tif y cr iti ca l H AI ev en ts , e sp ec ia lly r el at ed to em er ge nc e of A M R in di ca to r ba ct er ia a ga in st c ri tic al d ru gs Sa ni ta tio n an d H yg ie ne N o po lic y or c am pa ig n on s an ita tio n an d hy gi en e in in st itu tio ns or in c om m un iti es . N o da ta o n sa fe ly m an ag ed w at er s up pl y or s an ita tio n se rv ic es P ol ic y or c am pa ig n on sa ni ta tio n an d hy gi en e in in st itu tio ns o r in co m m un iti es in p la ce . Li m ite d da ta o n sa fe ly m an ag ed w at er s up pl y or s an ita tio n se rv ic es P ol ic y or c am pa ig n to im pr ov e sa ni ta tio n an d hy gi en e im pl em en te d in lim ite d sc al e. D at a on s af el y m an ag ed w at er s up pl y or s an ita tio n se rv ic es e xi st b ut a cc es s lo w P ol ic y or c am pa ig n to im pr ov e sa ni ta tio n an d hy gi en e is im pl em en te d at la rg e sc al e. D at a on s af el y m an ag ed w at er s up pl y or s an ita tio n se rv ic es e xi st a nd a cc es s m ed iu m P ol ic y or c am pa ig n to im pr ov e sa ni ta tio n an d hy gi en e is im pl em en te d w ith M & E m ec ha ni sm . Ac ce ss to s af el y m an ag ed w at er s up pl y or s an ita tio n se rv ic es h ig h Va cc in at io n N o fo rm al c am pa ig n on s an ita tio n & h yg ie ne a nd va cc in at io n Fo rm al c am pa ig n to en ha nc e on s an ita tio n & hy gi en e an d va cc in at io n be in g de ve lo pe d Fo rm al c am pa ig n to en ha nc e on s an ita tio n & hy gi en e an d va cc in at io n is im pl em en te d in s m al l s ca le Fo rm al c am pa ig n to en ha nc e on s an ita tio n & hy gi en e an d va cc in at io n is im pl em en te d in la rg e sc al e Fo rm al c am pa ig n to e nh an ce on s an ita tio n & h yg ie ne a nd va cc in at io n is im pl em en te d in la rg e sc al e & a ss oc ia te d w ith M & E sy st em 121 Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 6. Research and innovation R & D a nd in no va tio n on A M R p re ve nt io n an d co nt ai nm en t ( + R es ea rc h fu nd in g) N o po lic ie s fo st er in g re se ar ch e nv ir on m en t al th ou gh c ap ac ity e xi st s fo r re se ar ch P ol ic ie s pl an ne d an d ex is tin g st ru ct ur e ha s a pl an to fo st er r es ea rc h an d in no va tio n on A M R P re se nc e of p ol ic ie s an d in ve st m en ts to fo st er r es ea rc h an d in no va tio n on A M R R es ea rc h co ns or tiu m , dy na m ic r es ea rc h pr og ra m m es a re o ng oi ng th an ks to g ov er nm en t- le d ag en da G ov er nm en t- le d re se ar ch ou tp ut s re la te d to A M R gl ob al r es ea rc h ag en da 122 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 7. One Health engagement A na tio na l A M R co nt ai nm en t p ol ic y an d re gu la to ry fr am ew or k to co nt ro l r el ea se o f AR a nd A M R in to th e en vi ro nm en t an d m an ag em en t th er ei n N o na tio na l p ol ic y to re du ce a nt im ic ro bi al co nt am in at io n in to en vi ro nm en t. N o re gu la tio ns co nt ro lli ng A R em is si on s fr om an tim ic ro bi al m an uf ac tu re rs , ho sp ita ls o r w as te w at er tr ea tm en t p la nt s N at io na l p ol ic y to re du ce a nt im ic ro bi al w as te g en er at io n de ve lo pe d an d ap pr ov ed . R eg ul at io ns in pl ac e co nt ro lli ng AR e m is si on s fr om a nt im ic ro bi al m an uf ac tu re rs , ho sp ita ls o r w as te w at er tr ea tm en t p la nt s Ev id en ce o f im pl em en ta tio n of po lic y or r eg ul at io ns bu t l im ite d ca pa ci ty fo r m on ito ri ng P ol ic y or r eg ul at io ns im pl em en te d w ith s om e ca pa ci ty fo r m on ito ri ng bu t n o en fo rc em en t ca pa ci ty P ol ic y or r eg ul at io ns im pl em en te d w ith a de qu at e ca pa ci ty fo r m on ito ri ng a nd fo r en fo rc em en t N at io na l su rv ei lla nc e of AR a nd A M R in w as te w at er fr om m an uf ac tu re a nd hu m an /a ni m al /fi sh us e an d di sp os al in in st itu tio ns a nd th e ho m e N o/ w ea k na tio na l po lic y an d gu id el in es fo r su rv ei lla nc e of A R / AM R in w as te a nd en vi ro nm en t P ol ic y an d gu id el in es in p la ce b ut li m ite d ca pa ci ty fo r su rv ei lla nc e in a ny A R /A M R w as te g en er at io n or en vi ro nm en t l oc at io n So m e ca pa ci ty a nd da ta g en er at ed fr om A R /A M R w as te g en er at io n or e nv ir on m en t lo ca tio ns So m e da ta a na ly si s of A R / AM R in d iff er en t w as te ge ne ra tio n or e nv ir on m en t lo ca tio ns Co m pr eh en si ve a pp ro ac h of s ur ve ill an ce w ith co or di na te d an al ys is w ith hu m an a nd a ni m al AM R a w ar en es s ge ne ra tio n & ed uc at io n in th e en vi ro nm en ta l se ct or N o po lic ie s or ta rg et ed co m m un ic at io n st ra te gi es o n AM R in w as te o r on ly pl an ne d (fo r an tib io tic m an uf ac tu re rs , ho sp ita ls , w as te w at er tr ea tm en t i ns tit ut io ns , fa rm er s) P ol ic ie s or ta rg et ed co m m un ic at io n st ra te gi es d ev el op ed (fo r in st itu tio ns li st ed in P ha se E xp lo ra tio n an d Ad op tio n) AM R in s om e pr e- se rv ic e tr ai ni ng an d/ or s om e sp ec ia l c ou rs es (f or in st itu tio ns li st ed in P ha se E xp lo ra tio n an d Ad op tio n) Co nt in uo us p ro fe ss io na l de ve lo pm en t a nd r eg ul ar au di t o f l ea rn in g (fo r in st itu tio ns li st ed in P ha se Ex pl or at io n an d Ad op tio n) As se ss m en t o f t he un de rs ta nd in g by pr of es si on al s/ te ch ni ci an s, an d im pa ct o f, ed uc at io n pr og ra m m es o n pe rf or m an ce 7. O ne H ea lt h e ng ag em en t c on td . 123 Fo cu s A re as In di ca to rs / P ha se s Ex pl or at io n an d ad op ti on P ro gr am in st al la ti on In it ia l im pl em en ta ti on Fu ll o pe ra ti on Su st ai na bl e op er at io n 8. Overarching coordination mechanism for One Health engagement 8. 1 O ve ra rc hi ng AM R c oo rd in at io n m ec ha ni sm is e xi st in g be tw ee n al l r el ev an t se ct or s* N o fo rm al m ul tis ec to ra l go ve rn an ce o r co or di na tio n m ec ha ni sm ex is ts M ul tis ec to ra l w or ki ng g ro up (s ) or c oo rd in at io n co m m itt ee o n AM R e st ab lis he d w ith G ov er nm en t le ad er sh ip M ul tis ec to ra l w or ki ng gr ou p( s) is (a re ) f un ct io na l, w ith c le ar te rm s of r ef er en ce ; re gu la r m ee tin gs , a nd fu nd in g fo r w or ki ng g ro up (s ). Ac tiv iti es an d re po rt in g/ ac co un ta bi lit y ar ra ng em en ts a re d efi ne d Jo in t w or ki ng o n is su es in cl ud in g ag re em en t on c om m on o bj ec tiv es , in cl ud in g re st ri ct io n of us e of c ri tic al ly im po rt an t an tim ic ro bi al s In te gr at ed a pp ro ac he s us ed to im pl em en t t he n at io na l AM R a ct io n pl an 8. 2 In cl us io n an d en ga ge m en t o f a ll re le va nt s ec to rs in th e N AP -A M R N o fo rm al m ul tis ec to ra l go ve rn an ce o r co or di na tio n m ec ha ni sm ex is ts M ul tis ec to ra l w or ki ng g ro up (s ) or c oo rd in at io n co m m itt ee o n AM R e st ab lis he d w ith G ov er nm en t le ad er sh ip M ul tis ec to ra l w or ki ng gr ou p( s) is (a re ) f un ct io na l, w ith c le ar te rm s of r ef er en ce ; re gu la r m ee tin gs , a nd fu nd in g fo r w or ki ng g ro up (s ). Ac tiv iti es an d re po rt in g/ ac co un ta bi lit y ar ra ng em en ts a re d efi ne d Jo in t w or ki ng o n is su es in cl ud in g ag re em en t on c om m on o bj ec tiv es , in cl ud in g re st ri ct io n of us e of c ri tic al ly im po rt an t an tim ic ro bi al s In te gr at ed a pp ro ac he s us ed to im pl em en t t he n at io na l AM R a ct io n pl an . 8. 3 A pl at fo rm a nd / or m ec ha ni sm fo r sh ar in g of A M U m on ito ri ng d at a fr om al l r el ev an t s ec to rs ex is t N ot hi ng Ad -h oc D at a fr om d iff er en t s ec to rs co lle ct ed a nd in te rm itt en tly sh ar ed Co m pa tib le d at a fr om se ct or s co lle ct ed s ep ar at el y bu t c ol la te d, s ha re d an d di sc us se d in m ea ni ng fu l fo rm at w ith a c oo rd in at io n m ec ha ni sm to fa ci lit at e th is Fu lly in te gr at ed p la tf or m w ith c om bi ne d da ta th at is fe d ba ck to s ec to rs 8. 4 A pl at fo rm a nd / or m ec ha ni sm fo r sh ar in g of A M R su rv ei lla nc e da ta fr om al l r el ev an t s ec to rs ex is t N ot hi ng Ad h oc - un co or di na te d, pr oj ec t b as ed w hi ch c ov er s su rv ei lla nc e in m ul tip le s ec to rs D at a fr om a t l ea st tw o se ct or s an d sh ar ed a nd d is cu ss ed w ith c om pa tib le to ol s an d pr ot oc ol s fo r re le va nt s ec to rs to e na bl e ex am in at io n of tr an sm is si on p at hw ay s de ve lo pe d an d te st ed Sy st em s lo ok in g at tr an sm is si on p at hw ay s w ith c om pa tib le to ol s an d pr ot oc ol s fo r re le va nt se ct or s Fu lly in te gr at ed s ys te m co ve ri ng a ll pr io ri ty pa th og en s w ith c on si st en t m et ho do lo gy fo r Q A an d da ta fr om h um an , a ni m al an d en vi ro nm en t s ec to rs 8. 5 AA W is n at io na lly co or di na te d an d ce le br at ed w ith in vo lv em en t a nd co nt ri bu tio ns fr om a ll re le va nt s ec to rs N ot -c oo rd in at ed Co or di na te d AA W m es sa gi ng AA W im pl em en te d jo in tly in tw o se ct or s AA W im pl em en te d jo in tly in m or e th an tw o se ct or s Co or di na te d ca m pa ig n be yo nd A AW i. e. c on tin uo us 8. 6 A m ec ha ni sm fo r co -s ha ri ng o f re so ur ce s fo r AM R in iti at iv es in th e co un tr y ex is t N o m ap pi ng o f re so ur ce s. M et ho d to id en tif y ex is tin g re so ur ce s Co re e le m en ts i. e co m m itt ee , et c. r es ou rc es O th er k ey in te rv en tio ns id en tifi ed a nd c os te d Co or di na te d m ec ha ni sm fo r re so ur ce a llo ca tio n be tw ee n se ct or s is fu nc tio na l *S ec to rs a cti ve ly in vo lv ed in d ev el op in g an d im pl em en ti ng t he A M R N ati on al A cti on P la n in cl ud e am on g ot he rs h um an h ea lt h, a ni m al h ea lt h (t er re st ri al a nd a qu ati c) , p la nt h ea lt h, fo od p ro du cti on , f oo d sa fe ty , e nv ir on m en t, W A SH , t ra de , p ri va te s ec to rs a nd c iv il so ci et y 124 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Annex 3: List of participants Back-to-back intercountry meetings were held to review the implementation of the national action plans on antimicrobial resistance in Bangkok, Thailand, in July 2018. Meeting 1: 23–25 July 2018: Bhutan, DPR Korea, Maldives, Nepal, Sri Lanka and Timor-Leste Meeting 2: 25–27 July 2018: Bangladesh, India, Indonesia, Myanmar and Thailand Bangladesh Sarwar Jahan Pia Assistant Chief National Control Laboratory Directorate General of Drug Administration Dhaka Email: jahan.sarwat@yahoo.com Md Razibul Habib Superintendent of Drugs Directorate General of Drug Administration Dhaka Email: mrhjewel@gmail.com Md Mahbub Hossain Superintendent of Drugs Directorate General of Drug Administration Dhaka Email: mhossainbmb@gmail.com Bhutan Raghunath Sharma Laboratory officer Jigme Dorji Wangchuck National Referral Hospital Thimphu Email: regunathsharma959@yahoo.com Thupten Tshering Senior pharmacist Jigme Dorji Wangchuck National Referral Hospital Thimphu Email: thuptent@idwnrh.gov.bt Pema Yangzom Programme Officer Health-care and Diagnostic Division Department of Medical Services Thimphu Email: pyangzom@health.gov.bt Nirmal Kumar Thapa Animal health specialist National Center for Animal Health Department of Livestock, Ministry of Agriculture and Forests Thimphu Email: nkthapa08@hotmail.com Tashi Dendup Regulatory Officer Drug Regulatory Authority Thimphu Email: tdhendup@dra.gov.bt DPR Korea Han Jong Ryol Senior officer State Hygiene Control Board Ministry of Public Health Pyongyang Hong Sun Gil Vice-Director Veterinary and Anti-Epizootic Institute Ministry of Agriculture Pyongyang 125 Kang Song Guk Section chief Central Medication Research Institute Medical Science Academy Pyongyang Mun Hye Son Section chief National Regulatory Authority Pyongyang Jon Song Hui Official Department of External Affairs Ministry of Public Health Pyongyang Kim Se Hun Senior officer Department of Medicine Management Ministry of Public Health Pyongyang India Lata Kapoor Joint Director (Specialist Grade) National Centre for Disease Control Directorate General of Health Services, Sham Nath Marg Delhi Email: lata.kapoor@gov.in Arti Bahl Joint Director – Epidemiology Division National Centre for Disease Control Directorate General of Health Services, Sham Nath Marg Delhi Email: artichitkara@rediffmail.com Adhiraj Mishra Livestock officer Department of Animal Husbandry, Dairying and Fisheries Ministry of Agriculture and Farmers’ Welfare Government of India New Delhi Email: adhiraj123@yahoo.com Indonesia Harry Parathon Chief Committee for Antimicrobial Resistance Control Ministry of Health, Republic of Indonesia Jakarta Email: hparathon@yahoo.com Dyah Armi Riana National Officer-in-Charge, Human, Animal and Environment Centre for R&D of Biomedical and Basic Health Technology NIHRD, Ministry of Health Jakarta Email: dyaharmiriana@gmail.com Yurike Elisa Dewi Head of veterinary drug quality section Veterinary Drug Sub-directorate, Directorate of Animal Health Directorate General of Livestock and Animal Health Services Ministry of Agriculture Republic of Indonesia Jakarta Email: yedewie@yahoo.com Nani H. Widodo Head of subdivision and nursing services Directorate of Referral Health Ministry of Health Jakarta Email: naniwidodo@gmail.com Nanang Yunarto National Laboratory Representative Centre for R&D of Biomedical and Basic Health Technology National Institute of Health Research and Development Jakarta Email: nayunandesba@yahoo.com Erie Gusnellyanti Head of section of rational use of drug promotion Directorate of Pharmaceutical Services Ministry of Health Jakarta Email: erie.gn@gmail.com Joan Aprilla Arland GDP lead inspector, NADFC Jakarta Email: joan.arland@yahoo.com Hanny Musytika Head of section for standardization of safety and efficacy of new drugs, Biological Products and Investigational New Drugs, NADFC Jakarta Email: hanny.musytika@gmail.com Maldives Fathimath Reesha Laboratory technologist National Referral Laboratory representative Male Email: reesha7935222@gmail.com 126 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Shreefa Adam Manik Director General Ministry of Health Male Email: shareefa@health.com.mv Ismail Ajmal Environmental Analyst Ministry of Environment Male Email: ismail.ajmal@environment.gov.mv Aishath Mohamed Deputy Director-General, Pharmaceuticals National Drug Regulatory Authority Male Email: aishathmohamed@health.gov.mv Ibrahim Sujau Consultant in medicine Male Email: i-shaujau@hotmail.com Aminath Shafia Director-General Ministry of Fisheries and Agriculture Male Email: shafia.aminath@fishagri.gov.mv Myanmar Khin Nyein Zan Consultant microbiologist National Health Laboratory Department of Medical Services Yangon Email: ihdmoh@mptmail.net.mm Wutt ye Tin Maung Assistant director National Health Laboratory Department of Medical Services Yangon Email: wuttye84@gmail.com Aye Lwin Assistant director (CEU) Department of Public Health Naypyitaw Email: ayelwin169@gmail.com Kyi Kyi Swe Medical officer National Tuberculosis Control Programme Mandalay Email: drkyikyiswe1986@gmail.com Zaw Myo Latt Medical officer (CEU) Department of Public Health Naypyitaw Email: zawmyolatdr@gmail.com Syaw Wynn Veterinary officer Livestock, Breeding and Veterinary Department Ministry of Agriculture, Livestock and Irrigation Yangon Email: dr.sn.wynn.12005@gmail.com Nepal Salina Manandhar Senior veterinary doctor Vetenary Public Health Office Tripureswar Kathmandu Email: Smanandhar76@yahoo.com Runa Jha Director National Public Health Laboratory Department of Health Services Kathmandu Email: runa75jha@yahoo.com Bibek Kumar Lal Deputy Director-General Department of Health Services Kathmandu Email: bibeklal@outlook.com Sangita Shah Drug administrator Ministry of Health and Population Kathmandu Email: sangitashah295@gmail.com Satish Kumar Deo Clinical pharmacologist Tribhuvan University Teaching Hospital Kathmandu Email: satdeo@gmail.com Sri Lanka B V S H Beneragama Acting additional secretary (Medical Services) Ministry of Health, Nutrition and Indigenous Medicine Colombo Email: sbeneragama@hotmail.com R M Monika Nandani Pharmacist Medical Research Institute Colombo Email: rmn.nmra@gmail.com 127 K Jayathilake Consultant clinical microbiologist Sri Jayawardenapura General Hospital Colombo Email: kjayatilleke@gmail.com S S P Silva Director, Veterinary Research Institute Peradeniya Email: susil_vri@yahoo.com P M Mahinda Gunarathne Director, Policy Planning and Monitoring Ministry of Mhaweli Development and Environment Email: pmmgun@yahoo.com Thailand Suchart Chongprasert Director Bureau of Drug Control Food and Drug Administration Ministry of Public Health Bangkok Email: drsurchart@gmail.com Nithima Sumpradit Pharmacist, professional level Bureau of Drug Control Food and Drug Administration Ministry of Public Health Bangkok Email: nithima@fda.moph.go.th Weerawat Manosuthi Acting medical officer Bamrasnaradura Infectious Diseases Institute Department of Disease Control Ministry of Public Health Bangkok Email: idweerawat@yahoo.com Julaporn Sirnha Veterinarian, senior professional level Animal Feed and Veterinary Products Control Department of Livestock Development Ministry of Agriculture and Cooperatives Bangkok Email: Julaporn19_dld@yahoo.com Kingdao Intarukdach Environmentalist, senior professional level Water Quality Management Bureau Pollution Control Department Ministry of Natural Resources and Environment Bangkok Email: Kingdao78@hotmail.com Noppavan Janejai Medical scientist, senior professional level National Institute of Health Department of Medical Sciences Bangkok Email: Noppavan.j@dmsc.mail.go.th Timor-Leste Mario Amaral AMR national focal point Veterinary Diagnostic Laboratory Dili Email: amaralmario@yahoo.com Frederico Amaral AMR national focal point Veterinary Diagnostic Laboratory Dili Email: fredy13@yahoo.com Delfim da C X Ferreira National Director Pharmacy and Medicine Dili Email: delfim_costa@gmail.com Suzana Soares Hendriques AMR national focal point Ministry of Health Dili Email: suzanasoares06@gmail.com Florbela Viana AMR national focal point National Laboratory Dili Email: florbelaviana@yahoo.com Feliciano da Conceicao AMR national focal point Ministry of Agriculture and Fisheries Dili Email: maularavets@yahoo.com Temporary Advisers Visanu Thamlikitkul Director WHO Collaborating Centre for AMR Prevention and Containment Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand Email: visanu.tha@mahidol.ac.th Wantana Paveenkittiporn Head WHO Collaborating Centre for AMR Surveillance and Training National Institute of Health, Nonthaburi, Thailand Nonthaburi Email: wantana.p@dmsc.mail.go.th 128 Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 Siriraj Hospital Pinyo Rattanaumpawan WHO Collaborating Centre for AMR Prevention and Containment Faculty of Medicine, Siriraj Hospital, Mahidol University Thailand Email: pinyohiso@yahoo.com Rujipas Sirijatuphat WHO Collaborating Centre for AMR Prevention and Containment Faculty of Medicine, Siriraj Hospital, Mahidol University Thailand Email: rujipas.sir@mahidol.ac.th Special Invitees Viroj Tangcharoensathien Senior advisor to the International Health Policy Programme (IHPP) Ministry of Public Health Bangkok Email: viroj@ihpp.thaigov.net FAO Katinka de Balogh Senior Animal Health and Production Officer Food and Agriculture Organization Regional Office for Asia and the Pacific 39 Phra Atit Road, Phranakon Bangkok Email: Katinka.DeBalogh@fao.org Mary Joy Gordoncillo AMR Regional Surveillance Coordinator Food and Agriculture Organization Regional Office for Asia and the Pacific 39 Phra Atit Road, Phranakon Bangkok Email: Mary.Gordoncillo@fao.org Henk Jan Ormel Senior veterinary policy advisor Animal Health Service Food and Agriculture Organization Italy, Rome Email: HendrikJan.Ormel@fao.org OIE Pennapa Matayompong Programme Coordinator World Organization for Animal Health C/o Department of Livestock Development Bangkok Email: p.matayompong@oie.int Pasang Tshering Consultant OIE Regional Representation for Asia and the Pacific Email: p.tshering@oie.int Other agencies/ NGOs/ donors Kakuko Nagatani-Yoshida Regional Coordinator for Chemicals, Waste and Air Quality UN Environment Asia and the Pacific Office Room #0208, Wing A, 2nd Floor, The United Nations Building Rajadamnern Nok Avenue, Dusit Bangkok 10200, Thailand Email: kakuko.nagatani@unep.org or nagatani-yoshida@un.org Masato Motoki Environment and health officer Asia and the Pacific Office Economy Division UN Environment UN Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand Email: masato.motoki@un.org Montira Pongsiri Senior research associate, Planetary Health Science Policy Cornell University, College of Veterinary Medicine Department of Population Medicine and Diagnostic Sciences Atkinson Center for a Sustainable Future Faculty Fellow Bangkok, Thailand Email: mjp329@cornell.edu Sudarat Damrongwatanapokin Regional Animal Health Advisor Office of Public Health, US Agency for International Development Regional Development Mission, Asia Athenee Tower Wireless Road, Lumphini, Pathum Wan Bangkok 10330 Email: sdamrongwatanapokin@usaid.gov Anchalee Jatapai Global Health Security and Development Advisor Office of Public Health, US Agency for International Development Regional Development Mission, Asia Athenee Tower, Wireless Road, Lumphini, Pathum Wan Bangkok 10330 Email: ajatapai@usaid.gov WHO country AMR focal points Anuj Sharma National professional officer (AMR and Laboratories) WHO Country Office India Email: sharmaan@who.int Benyamin Sihombing National professional officer WHO Country Office, Indonesia Email: sihombingb@who.int 129 Mya Yae Mon National professional officer WHO Country Office, Myanmar Email: yeemonm@who.int Samuel Reuben Technical officer (Emergency Preparedness) WHO Country Office, Nepal Email: samuelr@who.int Richard Brown WHO Country Office, Thailand Email: brownr@who.int Observers Arlyne A. Beeche Senior programme specialist Agriculture and Environment International Development Research Center, Asia Regional Office Jor Bagh, New Delhi India Email: abeeche@idrc.ca Nareerut Pudpong, Researcher Email: nareerut@ihpp.thaigov.net Sunicha Chanvatik, Researcher Email: sunicha@ihpp.thaigov.net Angkana Sommanustaweechai, Researcher Email: angkana@ihpp.thaigov.net Wanwisa Kaewkhankhaeng, Research assistant Email: wanwisa@ihpp.thaigov.net Parinda Seneerattanaprayul, Coordinator Email: parinda@ihpp.thaigov.net Sukanya Numsawat Email: pharmatug@hotmail.com Raththar Benchapalanon Email: raththar.b@gmail.com Kulsumpun Krobanan Email: kulsumpunmew@gmail.com Sirima Punnin Email: sirima.punnin@gmail.com Sasi Jaroenpoj Veterinarian, expert level Division of Animal Feed and Veterinary Products Control Department of Livestock Development Ministry of Agriculture and Cooperatives Thailand E mail: sasijaroenpoj@yahoo.com Thammarath Sujit Veterinarian, senior professional level Bacteriology and mycology section National Institute of Animal Health (NIAH) 50/2 Kasetklang, Ladyao, Chatuchak, Bangkok 10900 Thailand Email: thammarathh@hotmail.com Supaporn Wongsrichai Veterinarian, Professional level Bureau of Quality Control of Livestock Products; BQCLP Email: paw_dld@yahoo.com WHO secretariat Prof Tjandra Aditama Senior Advisor to Regional Director WHO Regional Office for South-East Asia Email: aditamat@who.int Sirenda Vong Programme Area Manager Health Information Management and Risk Assessment WHO Regional Office for South-East Asia Email: vongs@who.int Manish Kakkar Medical Officer Health Information Management and Risk Assessment WHO Regional Office for South-East Asia Email: kakkarm@who.int David Sutherland Consultant, Tripartite Secretariat Health Information Management and Risk Assessment WHO Regional Office for South-East Asia Email: sutherlandda@who.int Oo Moe Medical officer Health Information Management and Risk Assessment WHO Regional Office for South-East Asia Email: moo@who.int Elizabeth Tayler Technical Officer, AMR Secretariat WHO Headquarters, Geneva Email: taylere@who.int Pravarsha Prakash Technical Officer WHO Headquarters, Geneva Email: prakashpra@who.int Klara Tisocki Regional Adviser - Essential Drugs and Other Medicines WHO Regional Office for South-East Asia Email: tisockik@who.int Manisha Shridhar Regional Adviser - Intellectual Property Rights and Trade & Health WHO Regional Office for South-East Asia Email: shridharm@who.int Kuldeep Sharma Executive Assistant Health Information Management and Risk Assessment WHO Regional Office for South-East Asia Email: sharmak@who.int