Post on 07-Aug-2020
27-Mar-18 National Health Laboratory
Yangon, Myanmar
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Regional Workshop on AMR in
South East Asia
Penang (Malaysia):
26-28 March 2018
Prof : Htay Htay Tin
drhtayhtaytin@gmail.com
DDG ( Laboratory)
National Health Laboratory
National Focal Point for AMR
Ministry of Health and Sports
Myanmar
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Yangon, Myanmar
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Yangon, Myanmar
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Myanmar National Action Plan on AMR
(NAP-AMR) in Line with Global Action Plan
on AMR ( GAP-AMR) as at 2018 January
Presence of national AMR multi-sectoral
committee and NAP-AMR in line with
GAP-AMR
- National AMR Multisectoral Committee
(Established) 2018 January
-NAP-AMR Launched ..2017 July
Awareness campaigns to the public -WAAW .. Held in 2017 November
-Some government-led activities in parts
of the country to raise awareness about
AMR and actions to address it
Education and training strategies for
professionals
-Relevant policies developed and ad-hoc
training courses in some disciplines
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Yangon, Myanmar
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National human AMR surveillance -Covering over 40 public hospitals
-Guidelines developed but not fully
implemented, limited quality data
Laboratory capacity
strengthening
-N.H.L is recognised as National AMR lab of Myanmar at present-DDG (Lab) is National Focal point of Laboratory capacity
strengthening
Early warning systems No effective system in place
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Yangon, Myanmar
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Rational use of antimicrobials and
surveillance of Use & Sale
National policy for control of human use
of antimicrobials (AMR Stewardship
Program, AMSP)
National Drug Policy 2001
But weak to develop a plan to
National AMSP
NRA/DRA system set up for oversight
but not fully functional
National policy & plan on surveillance of
use of antimicrobials under development
or developed & approved but less
implemented
Rational use of antimicrobials and
surveillance of Use & Sale
Indicator 4.4 Regulation of finished
antibiotic products and active
pharmaceutical ingredients (APIs)
Regulation with limited capacity but
strategic planning in place for capacity
building and appropriate budgeting
-
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Yangon, Myanmar
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Infection Prevention Control & AMR
Stewardship program
Indicator 5.1 AMR stewardship program
in HCS
-Awareness of Infection Prevention
Control Committee and Team, SOPs,
Guidelines, Job Description and
Training to all level of health providers
-Weekly supervision with checklist
Infection Prevention Control & AMR
Stewardship program
Indicator 5.2 Surveillance of healthcare
associated infections (HAI)
- Weak surveillance of HAI
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Yangon, Myanmar
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Infection Prevention Control & AMR
Stewardship program
Indicator 5.3 IPC program in HCS
-Capacity building plans implemented in
selected healthcare facilities
_But cannot cover all levels of HCS
Infection Prevention Control & AMR
Stewardship program
Indicator 5.4 Sanitation & hygiene and
vaccination in the community
-Formal campaign to enhance sanitation &
hygiene and vaccination is implemented
-Hand hygiene campaign , Health
Education, Symposium )
- Award to the best IPC of HCS
Research & Development to Combat
AMR
Indicator 6.1 Research & development
and innovation on AMR prevention and
containment
Very few R&D
-Existing structure has a plan to foster
research and innovation on AMR
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Yangon, Myanmar
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Yangon, Myanmar
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Yangon, Myanmar
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2016, June
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Yangon, Myanmar
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NAP Governance Structure in Myanmar
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Yangon, Myanmar
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National Multisectoral Steering
Committee(NMSC) Combating AMR
Myanmar
Endorsed .. 2018 January
• Chairman.. Union Minister of Health and
Sports
• 19 members from multisectoral in
One-Health approach
• DDG ( Labs ) .. Secretary
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Yangon, Myanmar
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Yangon, Myanmar
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Common Bacteria associated with
(HAI ) Hospital Acquired Infections :
WHO High Priority Pathogens
• Staphylococcus aureus
• Pseudomonas aeruginosa
• Acinetobacter species
• Escherichia coli
• Klebsiella species
Antibiotic susceptibility patterns of Escherichia coli in
Myanmar (2016)
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Yangon, Myanmar
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%89% 88%
83%78%
66%63%
56%52% 51%
44% 44%40% 40% 40%
34% 32% 32% 31% 29% 29% 27%
17%
8%
Pe
rce
nta
ge
Antibiotics
Antibiotic susceptibility patterns of Klebsiella species
in Myanmar (2016)
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Yangon, Myanmar
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
86%82%
74%
68% 67%64%
60% 60%
53% 52% 52% 50% 48%
40% 39% 38% 36% 34%
28%Pe
rce
nta
ge
Antibiotics
Antibiotic susceptibility patterns of Pseudomonas
aeruginosa in Myanmar (2016)
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Yangon, Myanmar
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
81% 81%75% 75%
65%
59% 57% 57%53% 53% 52%
49%
Pe
rce
nta
ge
Antibiotics
Antibiotic susceptibility patterns of Staphylococcus
species in Myanmar (2016)
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Yangon, Myanmar
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% 91%
79% 77% 74% 74% 74% 72% 71% 69% 67%
61% 60%56% 55% 54%
11%
Pe
rce
nta
ge
Antibiotics
*MRSA
Antibiotic susceptibility patterns of Acinetobacter
species in Myanmar (2016)
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Yangon, Myanmar
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
79% 78% 78%
68%
62%
45%42% 41% 40%
35%
28%25% 24%
5%
Pe
rce
nta
ge
Antibiotics
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Yangon, Myanmar
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WHO High Priority Pathogens in Myanmar
(ESBL producing Enterobacteriaceae, VRE and MRSA)(2016)
0%
10%
20%
30%
40%
50%
ESBL producing
Enterobacteriaceae, 47% Methicillin-resistant
Staphylococcus aureus, 40%
Vancomycin-resistant
Enterococcus species, 30%
Perc
en
tage
Pathogenic Bacteria
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➢Myanmar National Policy on Health Laboratories had
been disseminated in September, 2016
➢Development of National Strategic plan for Health
Laboratories : NSPHL (2017-2022) was adopted in
line with National Policy on Health Laboratories
➢ National surveillance for AMR is highly listed in
NSPHL
➢National Action Plan : NAP for AMR was endorsed
in endorsed in July. 2017 according to GLASS.
➢NMSC is endorsed on 2018 January .. Union Minister
of MoHS is Chairperson
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Yangon, Myanmar
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Role of NHL for AMR
➢ NEQAS – Identification and Antibiotic Sensitivity Testing of
Bacteria, (40) Central, Teaching, States, Regional and some
District Level Hospitals (2017)
➢ Participate in International EQAS, NIH, Thailand
➢ National Data collection from Hospitals and support to SOPs,
Guidelines
➢ Workshops on AMR (WHO)- Standard Laboratory Method
and Management of Data Entry (WHONET training)
➢ Standing as Reference Laboratory for AMR
Current activities on AMR
1.Collaboration with National Centre for Global Health and
Medicine (NCGM), Japan on their Whole Genome Sequencing of
Multi-drug resistant Gram Negative Bacteria
2.Technical Collaboration Agreement : Advancement in Clinical
practice through Microbiology Education” between Ministry of
Health and Sports, Myanmar & bioMérieux Pte.Ltd (Singapore) (
2018-2020)
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Yangon, Myanmar
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Activities of World Antibiotic Awareness
Week
Nay Pyi Taw
23.11.2017
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Yangon, Myanmar
Activities of World Antibiotic Awareness
Week
23.11.2017
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Yangon, Myanmar
Activities of World Antibiotic Awareness
Week
23.11.2017
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Yangon, Myanmar
Current activities ( Symposium on
Antimicrobial Resistance awareness at
46th Myanmar Research Congress)
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Yangon, Myanmar
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Laboratory perspective of combating AMR
(64th Myanmar Medical Conference)
(20.1.2018)
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Yangon, Myanmar
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Yangon, Myanmar
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Challenges in NAPAMR Limited Laboratory Capacity for AMR
Human resource
➢ Skill and training regarding clinical microbiology laboratory
for Microbiologists and technicians, staff rotation
➢ Staff motivation
Machines, Materials & Instruments for C&S
➢ Conventional C& S
➢ Automated – Vitek2, Bact Alert (FOC ?/Budget ?)
➢ Limited number of Biosafety Safety Cabinet
➢ Budget for full laboratory capacity support??
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Yangon, Myanmar
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Challenges in NAPAMR
Communication
➢ Communication between clinicians and the laboratory persons
in consulting antibiotic resistance pattern of various samples
➢Limited use of antibiogram result by clinician
➢ Clinical notes & diagnosis on request form.. Inadequate
➢ Unaffordable LIS Laboratory Information system effectively
➢ Data storage and Reporting- Limited IT facilities and internet
access in some labs (WHONET data analysis)
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Yangon, Myanmar
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Challenges in NAPAMR Sample Collection & Transportation.. Quality and timely
transportation of sample are critical considerations to get qualifiedAMR results.
➢ Space- Not enough working space
➢ Storage- Not enough lab equipments like refrigerator, deep freezer etc in some labs for samples storage
➢ Less awareness about the laboratory / health care associated infection , partly effected by their heavy workload and duties
➢ Waste disposal
-Difficult to get uniform colour coated plastic bag and waste container according to biosafety guideline / autoclavable bag
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Yangon, Myanmar
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Challenges in NAPAMR ➢ Limited use of antibiotic guidelines and antibiotic policy in some
hospitals ( AMU)
➢ Monthly CME and 3 monthly meeting in some hospitals but no regular meeting in some hospitals
➢ Less functional hospital Infection control committee meeting –annually/twice per year/Quarterly
➢ Unlimited access to laboratory working area
➢ Antibiotic Stewardship Program -not started yet in many hospitals
➢ Coordination between area of human and animal health based on one health approach
Health Care Associated Infection
Prevention and Control
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Yangon, Myanmar
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Yangon, Myanmar
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HIC ,Strengthening Symposium
February 2018
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Yangon, Myanmar
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HIC ,Strengthening Symposium
February 2018
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Yangon, Myanmar
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Current activities of IPC(Analysis of hospitals data as at Feb 2018)
Building the Infection Prevention Control Committee and team in hospitals
Awareness of Infection Prevention Control Committee and Team, SOPs, Guidelines, Job Description and Training to all level of health providers
Weekly supervision with checklist
Review and Reward
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Yangon, Myanmar
Current activities of IPC
(Analysis of hospitals data as at Feb 2018)
Providing the requirements to maintain the infection prevention control function
Fumigation of Operation theatre and labor room biannually
Following the hospital management guideline according to level of hospital
Health education about IPC to communities
Environmental sanitation activities collaborated with local authorities
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Yangon, Myanmar
Ways Forward (Short term)
Hospital antibiotic policy guideline
Infection control meeting - 3 monthly
Monitoring and evaluation – 6 monthly
Cooperation between patients wards and supportive department
Training and health education
Clinicians and Laboartory cooperation in monthly basis upon hospital antibiogram analysis
Requisition of separate budget for IPC
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Yangon, Myanmar
Ways Forward ( Short term)
Requisition of equipment and machines for IPC
Providing of clothing of patients and health providers
IPC checklist in every patients wards
Immunization of all health care providers with hepatitis B vaccine
Installation of exhausted fan at infectious patients room
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Yangon, Myanmar
Ways Forward (Medium & Long term)
IPC documents
(IPC policy, strategy, plan and guidelines)
Need national level IPC committee at MoHS..
-Compliance with IPC measures
-Routine surveillance of hospital acquired infection
Work closely with other national structure / department/ committee ( Multilateral cooperation)
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Yangon, Myanmar
Myanmar NEQAS of AST
• Started .. Since 2005
• National Health Laboratory is EQAS provider and
analyzer
• Now.. around 40 teaching hospitals , specialist
hospitals and State / Regional level public hospitals
are participated
• Then provide the data to WHONET
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Yangon, Myanmar
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Joint External Evaluation Process , GHSA
1• Stakeholders Meeting for JEE (6-2-2017)
2• Training on Internal Assessment Teams (21-2-2017) to (22-2-2017)
3• Internal Assessment Teams Visit (15-3-2017) to (22-3-201&)
4• Internal Assessment Teams Debriefing (6-4-2017)
5• Report to WHO (10-4-2017)
6• External Team Visit (3-5-2017) to (9-5-2017)
7• 5 years Strategic Plan for JEE (11-9-2017) to (15-9-2017)
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Yangon, Myanmar
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DDG ( Laboratory)
National Focal point of JEE / IHR in 3 areas
1.National Laboratory System strengthening
2. AMR
3. Biosafety
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Yangon, Myanmar
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JEE Report on
Antimicrobial Resistance , Myanmar
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Yangon, Myanmar
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JEE Recommendations on AMR,
Myanmar • Launch and disseminate the National action plan for
detection and reporting of priority AMR pathogen ( Done
at 2017 July)
• Sustain the quality and services of laboratories that are
able to detect and report priority AMR pathogen aligned
with the GLASS
( NHL as National AMR lab and WHONET courses)
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• Establish an evidence-based public communications
program targeting audiences in policy making, human
and animal health practice, the general public and
professional on prudent use of antimicrobials
( Underway)
• Sustain the surveillance capacity of existing 25 (human)
and 3 (animal) laboratory ( Now more on Human Health
surveillance laboratory to 40 numbers )
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Yangon, Myanmar
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JEE Recommendations on AMR, Myanmar
• Sustain the quality assessment scheme of NEQAS
• Develop surveillance system for usage of antimicrobial in human and animal
sectors (OH approach)
• Disseminate the National action plan that includes Hospital infection
prevention and control program ( Done )
• Implement according to the Hospital infection prevention and control
program in NAP ( Underway)
• Achieve a national steering committee for AMR and technical working
groups to coordinate and implement each objectives
( Established NMSC 0n 2018 Jan .. TWGs are developed accordingly)
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Yangon, Myanmar
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Yangon, Myanmar
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Future Works To Be Done
➢ National AMR Surveillance
➢ National Laboratory Network Strengthening
➢ Early Warning System for emerging drug resistance trends
➢ Strengthening of IPC and AMR Stewardship Programe in
Healthcare Setting
➢ WHONET....continuously implemented for epidemiological and
laboratory AMR surveillance data entry, storage and transmission in
human and animal sector labs
➢ & GLASS IT platform.. Will start soonest
Future Work To Be Done
Surveillance of rational antimicrobial use
• Establish a systematic, standardized process to collect, assess
and share data, maps and trends on AMR hazards
➢Promoting establishment of One health surveillance
➢ Cooperate AMR knowledge in undergraduate and post
graduate medical , nursing and basic health teaching curriculum
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