Post on 22-Jul-2019
An Ecohealth Approach to Develop a Strategy for the Prudent Use of
Antimicrobials to Control Antimicrobial Resistance in Human, Animal, and
Environmental Health in Asia
INDONESIA
Regional Meeting APEIR
Alaya Kuta Resort Hotel, Bali, 13-14 October 2016
Country Leaders
Dr. M.D. Winda WidyastutiIndonesia
Center for Indonesian Veterinary Analytical Studies
(CIVAS)
Dr. Fang Jing ChinaInstitute for Health Sciences, Kunming Medical University
Dr. Boualam Khamlome Lao PDRDepartment of Disease
Control, Ministry of health
Dr. Suvichai Rojanasthien
(Dr. Suwit Chotinum)Thailand
Faculty of Veterinary Medicine Chiang Mai
University
Dr. Nguyen Viet Khong VietnamNational Institute of Veterinary Research
Background
The burden of Antimicrobial resistance (AMR) in many Asiancountries is enormous
In developing countries, the problem of antimicrobial overuse orabuse in farms is worse due to weak law enforcement and the lackof drug-use monitoring
AMR is a complex, multi-dimensional and multi-factorial problemwhich involves various stakeholders at local, regional, national andinternational levels.
Need a trans-disciplinary approach and a wide range ofstakeholders must be involved to solve this problem
Develop an appropriate AMR containment strategy that isacceptable to multiple stakeholders, simple and practical, andadaptable is Essential
Ecohealth Principles
1. System Thinking
2. Transdisciplinary Research
3. Participation
4. Sustainability
5. Gender and social equity
6. Knowledge to action
Indonesia TeamNo. Nama Keahlian Institusi
1 Drs. Edi Basuno, M.Phil, PhD Socio-Economic and Community
Engagement
The Center for Agriculture Socio
Economics and Policy Studies
(ICASEPS), Ministry of Agriculture
2 Drh. Anak Agung Gde Putra, SH,
MSc, PhD
Veterinary Epidemiology Disease Investigation Centre,
Denpasar. Ministry of Agriculture
3 Drh. Iwan Willyanto, MSc, PhD Veterinary Public Health Private Consultant
4 Drh.med.vet. Hadri Latif, MSi Veterinary Public Health Bogor Agricultural University
5 Drh. Imron Suandy, MVPH Veterinary Laboratory Expert Quality Control Laboratory for
Livestock Product, Ministry of
Agriculture
6 Prof. dr. Agus Suwandono, MPH,
Dr.PH
Public Health Health Research and Development
Institute, Ministry of Health
7 dr. Anis Karuniawati, PhD, Sp.MK Microbiologist, Public Health Departement Microbiology, Faculty of
Medicine. University of Indonesia
8 Drh. Andri Jatikusumah, M.Sc Veterinary Epidemiology and
Veterinary Economic
Center for Indonesian Veterinary
Analytical Studies (CIVAS)
9 Drh. M.D. Winda Widyastuti, M.Si Veterinary Public Health,
Community Engagement
Center for Indonesian Veterinary
Analytical Studies (CIVAS)
10 Drh. Ridvana Dwibawa Darmawan GIS & Data, Participatory
Epidemiology
Center for Indonesian Veterinary
Analytical Studies (CIVAS)
11 Drh. Riana Aryani Arief, MS Veterinary Epidemiology Center for Indonesian Veterinary
Analytical Studies (CIVAS)
PAC Team
(1) SC APEIR – Prof. dr. Amin Soebandrio, Ph.D, Sp.MK
(2) Food and Drug Testing Agency (BPOM),
(3) DG of Health Improvement, Ministry of Health
(4) DG of Pharmaceutical and Referral Services, Ministry oh Health
(5) Directorate General of Livestock and Animal Health Services c.q. Directorate of Animal Health and Directorate of Veterinary Public Health, Ministry of Agriculture.
Objectives
To explore, develop and demonstrate the effectiveness of strategies on prudent use of antibiotics in human, animal and environment for antibiotics resistance mitigation program in Indonesia; using an ecohealth approach
Timeline Studi
Desk Study
Baseline Survey• Antibiotic useage• Antibiotic access• KAP study
Intervention• Public health• Animal health• Layer and pig farms
E. Coli sensitivity survey• Human isolates• Animal isolates• Environmental isolates
Local dissemination & advocacy• National workshop• Policy brief
Phase 1 . Phase 2 . Phase 3
Sept 2013 Sept 2016
Desk Study
Data collection:
1. Regulations related to antibiotic use in humans and animals;
2. Results of local and international study/research on antibiotic resistance in human, animals and the environment published in the last 10 years ago;
3. Guidelines and standards related to antibiotic resistance.
System review & Gap Analysis:
• to demonstrate how the system was functioning and how it should work under perfect conditions based on the data collected above. A gap analysis was performed to identify parts in the systems where discrepancies were considered important and identify stakeholders or system components involved.
Design & Method
Desk Study Result
ImporterProducer
Pharmaceutical Wholesalers
Health CentersHospital Pharmacy
Doctor (prescription)
Consumer
Drugstore
Government Association
Dirjen BinFarBPOM
Production and distribution permit
Monitoring and controlBPOM National level
Province Health OfficeCity/Regency Health Office
permit
Province levelBPOM
Monitoring and control
Indonesian Pharmaceutical Company
affiliation (GP Farmasi)
Indonesian Hospital Association (PERSI)
Indonesian Pharmacists Association
Indonesian Medical Association
Indonesian Pharmacy Association
Desk Study Result
ImporterProducer
Distributor
Veterinary Hospital
Veterinary Drug Depot
Veterinary Drugstore
Veterinarian (Medical Recomendation)
Farmer
Government Association
PPOH
Production and distribution permitSubdit POH
Livestock Office of Province Livestock Office of City/Regency
monitoring
BPMSPH (National)DIC (Regional)
monitoring
Indonesian Animal Drug Association (ASOHI)
Indonesian Veterinarian Association (PDHI)
Farmer Association
Farm Product Environment
residu Ab
KOH BBPMSOH
BBPMSOH (National)
monitoring
Baseline Survey
Design & Method
1. Survey on antibiotics usage & accessibility for farm and farmer KAP:
a. Layer (40 farms)
b. Pig (40 farms)2. Survey on antibiotics usage & accessibility for human and
human KAP:
a. Puskesmas (Community Health Centers/PHF) (40) & Hospitals (14)
b. Patients in PHF & hospitals (54 respondents)
c. Layer and pig farm workers (77 respondents )
d. Doctor in PHF/hospital (54 respondents )
3 district in Central Java = Sukoharjo, Klaten, Karanganyar
60
37.5
37.5
35
25
22.5
15
15
15
10
7.5
7.5
7.5
5
5
0 10 20 30 40 50 60 70
Enrofloxacin
Oxytetracycline
Tetracycline dan Erytromycin
Oxytetracycline dan Neomycin
Bacitracin
Doxycycline
Sulfadiazine dan Trimethoprim
Amoxicillin dan Colistin
Penicillin dan Streptomycin
Erytromycin
Sodium Sulfaquinoxaline
Ciprofloxacin
Amoxicillin
Doxycycline dan Erytromicin
Lincomycin
Percentage
Antibiotics
Baseline Survey Result (1)
Antibiotics Usage in Layer Farm
Baseline Survey Result (2)
Antibiotics Usage in Pig Farm
4525
22.520
12.512.5
7.55
2.52.52.52.52.52.5
0 10 20 30 40 50
Penicillin
Oxytetracycline
Sulfadiazine Trimetoprim
Penicillin Streptomycin
Streptomycine
Cephalosporin
Lincomycine Spectinomycine
Percentage
Antibiotics
Accessibility to get and use antibiotics in Farms
60
52.5
50
52.5 2.5 2.5
72.5
12.5
2.5
12.5
0 0 0 00
10
20
30
40
50
60
70
80
Poultry Shop/ Sapronak/ Toko obat
Technical Service
Obat/Pakan
Dokter hewan Petugas Dinas Peternakan
Koperasi Peternak
Keluarga Peternak
Perusahaan Induk
Langsung dari Perusahaan
Obat
Layer Babi
Percentage (%)
Baseline Survey Result (3)
Pig
Veterinarian Livestock Officers
Farmers Cooperative
Farmer’s Family
Production Company
Drugs Company
Technical Service
Feed/Drugs
Who is decide for using Antibiotics?
85
0 2.5 0
7.52.5
87.5
22.5
7.52.5 0 0
0
10
20
30
40
50
60
70
80
90
100
Pemilik Petugas dinas peternakan
Pekerja kandang
Dokter hewan Manajer peternakan
Perusahaan induk
Layer Babi
Baseline Survey Result (4)
Percentage (%)
Pig
VeterinarianLivestock Officers
Farm Workers
FarmManager
Production Company
Farmers / Owners
KAP Study for Farmers
Knowledge
62.5
30
7.5
27.5
67.5
5
01020304050607080
Positif Netral Negatif
Sikap (%)
Layer Babi
Positive
25 22.5
52.5
7.520
72.5
01020304050607080
Tinggi Sedang Rendah
Tingkat Pengetahuan (%)
Layer Babi
ModerateHigh
Pig
Attitude (%)
Baseline Survey Result (4)
Low
Neutral Negative
Attitude
Knowledge (%)Pig
Pig
Antibiotics Usage in Health FacilitiesHospital
Antibiotics %Average
usage (mg / month)
Amoxillin 100 2.650.267Trimethoprim-sulfamethoxazole
85 731.102
Ciprofloxacin 92,5 199.586Tetrasiklin 72,5 161.909Metronidazole 90 139.418Sefadroksil 77,5 113.109Kloramfenikol 92,5 86.701Eritromisin 82,5 83.242
Antibiotics %Average
usage (mg / month
Ceftriaxone 71,4 1.936.171Amoxicillin 92,9 1.862.963Sefadroksil 78,6 1.663.536Ciprofloxazine 78,6 1.622.033Metronidazole 78,6 292.974Cefixime 78,6 265.47Levofloxacin 85,7 182.441Clindasmisin 71,4 88.361Kloramphenicol 71,4 75.322Eritomisin 78,6 67.963Gentamisin 71,4 7.826
14 antibiotics 82 antibiotics
Baseline Survey Result (5)
PHF
• Knowledge Doctors in PHF = moderate, in Hospital = high Attitude = all Positive
• Practices:- Still irrational usage of antibiotics (decrease with Rational usage of antibiotics program from the MoHmonthly reporting for 2 diseases indicators : uppers resp. infection, diarhea non spesific)
- Still need for program /knowledge update especially for antibiotics several respondents stated not sure that they have do a prudent use
Basic information for intervention
KAP Study for Doctors in Health Facilities
Baseline Survey Result (6)
• PHF :stocking from health services at district level, doctors
can make prescription as needed to related pharmacyMonthly reporting & restocking
• Hospital:Government hospital: reporting to district health
services, stocking were coordinated with related company or private pharmacyPrivate hospital/private practitioners: no obligation to
report, only narcotics
Antibiotics Accessibility and Reporting in in Health Facilities
Baseline Survey Result (7)
KAP Study for Community (Antibiotics & AMR)
7.4 9.72.8
31.5
65.9
11.1
61.1
24.4
86.1
0
20
40
60
80
100
Pasien RS/Puskesmas (n=54)
Pekerja Peternakan Layer (n=41)
Pekerja Peternakan Babi (n=36)
Tinggi
Sedang
Rendah
Knowledge
Baseline Survey Result (8)
Layer Farms Workers(n=41)
High
PHF/Hospital Patients(n=54)
Moderate
Low
Pig Farms Workers(n=36)
57.4
34.138.940.7
65.9 61.1
1.90
10
20
30
40
50
60
70
Pasien RS/Puskesmas (n=54)
Pekerja Peternakan Layer (n=41)
Pekerja Peternakan Babi (n=36)
Positif
Netral
Negatif
Attitude
KAP Study for Community (Antibiotics & AMR)
Baseline Survey Result (9)
Layer Farms Workers(n=41)
PHF/Hospital Patients(n=54)
Pig Farms Workers(n=36)
Positive
Negative
Neutral
KAP Study for Community (Antibiotics & AMR)
Baseline Survey Result (10)
Practices:
Self medication Buy antibiotics without prescription at “warung” (household store) Stop using antibiotics when clinical sign decreaseGiving antibiotics to others Using “drug pocket” for certain clinical sign of diseases Basic condition for intervention program
Intervention Program
Boundary Partners (BP)
Animal Health sector:1. Animal health officers (district & sub-district level)2. Pilot farmers (10 pig farms, 6 layer farms)
Public Health sector:1. Public health officers (district & sub-district level)2. Village health-volunteer / cadres
Supporting partner: Village level (local government)
Outcome Mapping (AH)
Progress Marker Expect to See Like to see Love to see
AH OfficersAttend the PA meeting/discussion
Give positive response for farmer consultation
Actively doing PA or mentoring/visit to farmers
Understand better on indication and risk of AMR, and implement the prudent use of antibiotics
Initiate program for AMR PA for farmers or program mentoring
Outcome Mapping (AH)
Progress Marker Expect to See Like to see Love to see
Pilot Farmers
Attend the PA meeting/discussion
Actively participatein the PA meeting/ discussion/ evaluation program
Initiate better practices on farm healthmanagement, applicative biosecurity, etc
Have a contact number/person for AH services for their area
Actively consult / discuss with AH services officers
Encourage Other farmers to practiceand consult with vet/AH services officers
Able to identify kind of antibiotics they’re used
Using antibiotics for treatment based on correct diagnose/vet advices
Develop applicable recording for antibiotics usage in farm
Outcome Mapping (AH)
Progress Marker Expect to See Like to see Love to see
APH Officers
Attend the PA meeting/discussion
Give positive response for cadresconsultation
Actively doing PA or mentoring/visit /evaluation tovolunteers
Understand better on indication and risk of AMR, and implement the prudent use of antibiotics, doing PA in health facilities
Initiate upgrade for AMR PA or program mentoring for cadres
Outcome Mapping (PH)
Progress Marker Expect to See Like to see Love to see
Cadres
Attend the PA meeting/discussion
Practice the prudentuse of antibiotics in family
Initiate program for better practices on AMU in community
Understand better on AMU and AMR
Actively doing PA program in community
Encourage Other to promote and practice prudentAMU
Able to identify kind of antibiotics they’re used in family
Actively identify incorrect practices of AMU in community and give suggestionsto behavior changes
Actively discuss and regular linking with PH officers
BIJAK Antibiotics (BIJAK = prudent)
( key messages )Public Health Animal Health
B = Beli Buy with prescription
B = Beri Give for treatment, not for prevention
I = Ikuti Follow the rule of antibiotic usage
I= Ikuti Follow the rule of antibiotic usage
J = Jeli dan
berani
Aware dan be brave to ask doctors
J = Jaga masahenti obat
Aware for withdrawltime
A = Awasi Caring for antibiotics usage in family
A = Awasi Caring for antibiotics usage in farm
K = Konsultasi Consult with doctor
K = Konsultasi Consult with veterinarian / AH services
Animal Health Officers
Activities:
(1) Training for Facilitators (AB & AMR with ecohealthconcepts)
(2) Training for livestock officer on pig farming and health management
(3) Linking with farmers – involve them for regular mentoring
Intervention Result (1)
Pig & Layer Farmer (1)
Activities:
(1) Farm mentoring in every 2 weeks
(2) Information sharing:
- Antibiotics, AMR, health management & rearing management
- Basic recording
- Applicable Biosecurity practice
(3) Linking with Animal Health services (government / private)
Intervention Result (2)
Findings: - Farmers are eager to learn, but their learning capacity regarding
antibiotics and AMR are limited- Professional animal health services must be made available for
farmers- Farmers have poor confidence on current animal health services
and government services are also lacking
Potential sustainability / program adoption:- Reasonable to implement because it supports government
programs to strengthen veterinary services for small scale farmers
- Challenges: pigs (social, religion), human resources, program priority
Intervention Result (3)
Pig & Layer Farmer (2)
Public Health Officers
Activities:
(1) TOF - Training for Facilitators (AB & AMR with ecohealthconcepts)
(3) Linking with community – involve them for regular mentoring for volunteer/cadres
Intervention Result (4)
BIJAK Antibiotics Cadres/Volunteer (1)
Activities:
Process: FGDs, Training, Mentoring & Evaluation, linking with PH officers in village & subdistrict-district
Total = 93 person ( 88 = pilot villages; 5 = Observer village)
Local people as representatives of sub-villages (3-6 person) within pilot villages; existing health volunteer / non
trans - : gender, occupational , social status
Activities/duties:
1. Public Awareness
2. Information gathering from community (=incorrect practice of AMU)
Intervention Result (5)
Findings:
- Volunteer working in the community with passion, no-rewards (money) facilitated with PA media, incentives
- Community feel get advantages of the program for themselves & community
- Sensitively to collect information on many incorrect practices in community for AMU
- Still need regular mentoring & knowledge upgrade for problem found in community
Intervention Result (6)
BIJAK Antibiotics Cadres/Volunteer (2)
Potential sustainability / program adoption:- Reasonable to implement, effectively proven to provide
data in village level on AMU and detect the trend community practices/behavior
Challenges:- Need local government (villages/district) support
(Villages fund, village legitimation, etc)- Need reguler support and mentoring from PH services in
district & sub-district
Intervention Result (7)
BIJAK Antibiotics Cadres/Volunteer (3)
Biological Sampling
Biological Sampling
• E. coli isolates from animals, people and the environment
• Sample collection from:
– 27 small-scale pig farms
– 27 small-scale layer farms
• Phenotypic testing: Disk diffusion tests with 10 antibiotics from 7 groups
• Genotypic testing (ongoing)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMP AMC CEP CRO GEN CIP LVX CHL SXT TCY
E. coli from Pigs (n=126)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMP AMC CEP CRO GEN CIP LVX CHL SXT TCY
E. coli from Pig Farm Environment (n=50)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMP AMC CEP CRO GEN CIP LVX CHL SXT TCY
E. coli from Pig Farm Workers (n=44)
Resistant
Intermediate
Sensitive
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMP AMC CEP CRO GEN CIP LVX CHL SXT TCY
E. coli from Layer Chickens (n=405)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMP AMC CEP CRO GEN CIP LVX CHL SXT TCY
E. coli from Layer Farm Workers (n=43)
Resistant
Intermediate
Sensitive
Recommendation (1)
(1) Improve Control on AB Import, Production and Distribution
a. Strengthen government structure
Animal Drug Supervisors, etc (existing structure)
b. Increase regulation of antibiotics to be similar to narcotics
Recommendation (2)
(2) Implement AMR surveillance in farms and primary healthcare facilities
(3) Community engagement
Village cadres
Improve drug labeling to help identification by the public
Thank You