National Action Plan on Antimicrobial...
Transcript of National Action Plan on Antimicrobial...
National Action Plan on Antimicrobial Resistance
Dr Lata KapoorJoint Director
National Centre for Disease ControlMinistry of Health and Family Welfare
“It is not the strongest in the species
that survive or the most intelligent..
but the ones most responsive to change”
Charles Darwin
Antimicrobial resistance happens when bacteria change and become resistant to antibiotics used to
treat the infections they cause.
Why is AMR containment important
Threat posed by AMR to public health
• Threatens a therapeutic dead end in the treatment of bacterial infections
• Threat to the safety and effectiveness of procedures such as surgical
interventions, cancer treatment and organ transplants
• Delays in treatment lead to:
• Longer duration of illness and treatment increases health-care costs
and the economic burden to families and societies.
• Patients remain infectious for longer time, increasing the risk of
spreading resistant microorganisms to others.
Contributory factors• Inappropriate use (overuse, underuse and misuse) of antimicrobials in
• Clinical medicine (50% of antibiotics are prescribed inappropriately)
• Use of antibiotics as growth promoters in animals (More than 60% of human antibiotics used in animals)
• Veterinary medicine
• Agriculture
• Big Pharma industry for antibiotics, Inadequate effluent treatment: Environmental pollution
• Poor infection prevention and control in health care settings.
• Lack of hygiene and poor sanitation
• Use /availability of poor quality Antibiotics
• Inadequately regulated use of antibiotics, • Inadequate implementation of regulations (Schedule H-1/Schedule X for human use)
• Limited regulations for food animals (but no regulations in non-food animals)
• Lack of development of new antibiotics
• Lack of intersectoral approach
Other AMR related issues
• Medical education curriculum, limited knowledge about AMR issue
• Limited availability/utilization of microbiology laboratory capacity at district
hospitals and many state medical colleges, poor sample referrals
• Inadequate interaction among clinicians & laboratory
experts, Veterinarians, environmentalists
2010National Task Force set up
2011National Policy for Containment of AMR adopted
Sept 2011Jaipur Declaration by Health Ministers of South-East Asia Region
2012National Programme on AMR (pilot basis, now programme)
2017National action Plan on AMR (NAP-AMR) & Delhi Declaration
National response – containment of AMR
Delhi Declaration (19th April, 2017) - Ministers and policy makers from various Ministries under
GOI, assembled at the Inter-Ministerial Consultation on Antimicrobial Resistance pledge to adopt a
holistic and collaborative approach towards prevention and containment of AMR in India
National Action Plan on AMR (NAP-AMR)
• Three governance mechanisms constituted to
oversee AMR activities including development
and implementation of National Action Plan
• Core Working Group (CWG)
• Technical Advisory Group (TAG)
• Inter-sectoral Coordination Committee (ICC)
• Action plan endorsed by different stakeholder ministries in inter-ministerialmeeting chaired by Hon’ble HFM and launched on 19th April 2017
Development of National action plan
Three committees constituted to oversee various activities including development and Implementation of national action Plan
• Inter-sectoral coordination committee (ICC-AMR) chaired by Secretary Min of Health and family Welfare
• Technical advisory group (TAG) under the Joint Chairmanship of Director General of Health Services & Secretary Dept. of Health Research / Director General ICMR and
• Core Working Group (CWG) chaired by Director NCDC
Intersectoral coordinating committee
Technical advisory group
Core working group
Development of NAP-AMR
• Strategic framework for
NAP-AMRApr 2016
• Notification -governance mechanisms27 Sep 2016
• Core Working Group meeting
5 Oct 2016
• CWG sub-group meetings
Oct-Nov 2016
• National workshop
on NAP-AMR8-9 November
2016
• Second CWG meetingJan 2017
• TAG-AMR meeting
28 Feb 2017
• ICC-AMR meeting
12 April 2017
• Inter-Ministerial consultation on
AMR19 April
• National Consultation to Operationalise Action for AMR
containmentAug 2017
National action Plan on AMR (NAP-AMR): 6 strategic priorities
1. Awareness &
understanding
Communication & IEC
Education, training
2.Knowledge &
evidence
Surveillance of AMR –
human, animal, environment
Laboratories
3.Infection
prevention & control
Healthcare, HAI
Animal health
Community & environment
4.Optimise use
Regulations, access, AM use
Antimicrobial stewardship -
human
AMS -animals, agricult
ure
5.Innovations, R&
D
New medicines
Innovations
Financing
6.Leadership
International collaborations
National collaborations
State level collaborations
AMR stakeholders
• MoHFW
• NCDC, ICMR, CDSCO/DCGI,
FSSAI, NHM
• States
• Tripartite FAO-OIE-WHO
• Others
• Professional councils
• Professional associations
• Private sector
• NGOs
• Civil society
• 11 other ministries
• Agriculture and Farmers Welfare
• AYUSH
• Chemicals and Fertilizers
• Consumer Affairs, Food & Public Distribution
• Drinking Water and Sanitation
• Environment, Forest & Climate Change
• Finance
• Food Processing Industries
• Human Resource Development
• Information and Broadcasting
• Science and Technology
National AMR containment activitiesHuman Health
National level activities for AMR containment
Human Health
• AMR surveillance
• Promote rational use of antibiotics (National Treatment Guidelines for antimicrobial use , Antibiotic consumption studies, prescription audits)
• Hospital Infection Prevention and control ( National infection prevention and control guidelines), HAI surveillance initiated
• Schedule H1/ Schedule X to regulate sale of antibiotics in humans
• FSSAI : Regulations for antibiotics in foods
• Antimicrobial stewardship activities
• Initiated trainings on antibiogram development
• Raising Awareness about AMR
• Promotion of alternative systems of medicine through AYUSH programme
National Programme on Antimicrobial Resistance Containment
▪ As per National Policy, National Programme on AMR Containment was developedand approved for implementation during 12th Five Year Plan.
▪ NCDC, Delhi is identified as the nodal institution for this activity. Objectives of theprogramme:
▪ Establish a laboratory based AMR surveillance system in the country togenerate quality data on antimicrobial resistance
▪ Strengthen infection control practices
▪ Conduct surveillance of antimicrobial usage and Antimicrobial stewardshipactivities (AMSP) in health care settings to promote rational use of antimicrobials
▪ Generate awareness amongst health care providers and community onAntimicrobial resistance and rational use of Antimicrobials.
National Programme on AMR Containment
Phase I Sites
1 LHMC Delhi
2 Safdarjung Delhi
3 GMC Chandigarh
4 GSVM Kanpur
5 SMS Jaipur
6 BJMCAhmedabad
7 BJMC Pune
8 MMC &RI Mysore
Phase 2 Sites
9 KAPV Tiruchirappalli
10 GMC Trivandrum
11 GMC Guahati
12 MGM MC Indore
13 NEIGRIHMS Shillong
14 IGMC Shimla
Phase 3 Sites
15 GMC Aurangabad
16 OMC Osmania
17 GMCH Jammu
18 AGMC Agartala
19 GMC Guntur
20 SCB Cuttack
One lab in each state to become model for AMR surveillance
Support to Network Labs
▪ Manpower : Funds for recruiting Lab technician and data entry
operator
▪ Contingency : small amount of fund for Quality antibiotics procured
centrally and supplied funds given for purchase of other minor
reagents
▪ Equipments: Funds for purchase as well as Repair/maintenance
▪ Training : On Data analysis and quality control
▪ Guidelines : Made available current CLSI Guidelines, SOP,s
developed
▪ State medical colleges being strengthened in a phased manner to carry out
surveillance and other containment activities.
▪ 20 labs strengthened, total of 25 labs to be strengthened by 2020
▪ Surveillance SoP for data collection finalized and uploaded on website
▪ Clinical samples- blood, urine, aspirated pus and other body fluids
▪ Limited panel of antibiotics
▪ Pathogens: Staph aureus, Enterococcus spp., Escherichia coli, Klebsiella
spp., Pseudomonas spp., Acinetobacter spp. Salmonella enterica serotype Typhi
and Paratyphi
▪ Standardised SoP including the minimum data fields and AST methodology being
used by all network sites, available on NCDC website
▪ Data analysis tools identified as WHONET, training imparted
Activities under the programme
Challenges in implementation of National Programme on AMR containment
• Limited availability/utilization of microbiology laboratory capacity at district hospitals and many state medical colleges, poor sample referrals
• Limited hours of lab access pose hindrance for effective antimicrobial stewardship practices
• Medical education curriculum, limited knowledge about AMR issue
• Inadequate interaction among clinicians & laboratory experts
Challenges in AMR surveillance
• Limited lab capacity for culture and AST
• Available data mostly from IPD patients, from tertiary care Institutes
• Quality assurance in Culture and Antimicrobial sensitivity testing in labs
• Procurement of quality antibiotic discs
• Competent manpower
• Insufficient data analysis for guiding local antibiotic policy
• Limited networking of labs
Other National level initiatives
National Guidelines for use of antimicrobials
• National Guidelines for antimicrobial use in infectious diseases have been developed (Released by HFM in Feb 2016) and uploaded on NCDC website(www.ncdc.nic.in). It would serve as a guide to all the health care facilities to formulate their own guidelines.
Hospital Infection Prevention & Control guidelines
• An interim concise guideline on infection control has been uploaded on NCDC website as a ready reference for the hospitals to start implementing infection control practices in their settings.
▪ Detailed National Infection control guidelines is in finalization stage
Other activities
Enrolment on GLASS
▪ NCDC Notified National Coordinating Centre for AMR Surveillance
▪ India enrolled on Global Antimicrobial Surveillance System (GLASS) in July2017
▪ Data for 2017 for NCDC and ICMR surveillance network submitted
Surveillance of Health care associated infections:
▪ ICMR-AIIMS-NCDC-CDC network conducting surveillance of BSI & UTI
▪ Standardized definitions, software
▪ Developing preventive bundles
Schedule H-1.
• About 24 antimicrobials belonging to 3rd, 4th generation Cephalosporins and
Carbapenems are covered in the schedule.
• These antimicrobials cannot be sold without a proper medical prescription
• Drug packaging for these drugs is to be labeled with the following text along with
red border.“SCHEDULE H1 DRUG –
WARNING : It is dangerous to take the drug except in accordance with
medical advice, Not to be sold by retail without the prescription of a
Registered medical practitioner”,
• A separate register has to be maintained by the pharmacist giving details of the
prescriber, the patient as well as the drug sold.
FSSAI: notified minimum tolerance limits for 103 antibiotics in animal foods
Regulatory Strengthening
Implementation of NAP-AMR
• Stakeholder ministries and departments sent communications to:
• Identify nodal officers for AMR
• Develop operational plan for NAP-AMR implementation
• Identify and allocate budget
• National level consultation held to operationalise NAP-AMR
• FSSAI held meeting under Secretary (H) with CDSCO and DADF regarding implementation of notification on minimum residual limits of antibiotics in animal foods
• TAG-AMR meeting held in October 2018
• ICC-AMR meeting to be held in next quarter
Development State action plans for containment of AMR
• States to develop SAP for AMR
• Focus on minimum four strategic priorities:
• Improve awareness and understanding of AMR amongst policy makers, general public, farmers and other stakeholders.
• Strengthen AMR surveillance through strengthening laboratories in human, animal, food and environment sectors
• Reduce incidence of infections through effective infection prevention and control
• Optimise the use of antimicrobial agents in health, animals and food through strengthening regulations/implementation of existing regulations, antimicrobial stewardship in healthcare and optimise use of antibiotics in animal heath, food and agriculture sector
• Involving Stakeholders from various departments
• States sensitised at National consultation in August 2017
• Letters sent from Sec (H) in the month of June 2018,
• Guidance document for developing State action plan for containment of AMR
• Copy of NAP-AMR
• Technical consultation held on Jan 9th 2019 for developing state action plans on AMR along with patient safety, climate change
• Letter sent from MoHFW to states in May 2019 to identify dedicated state nodal officer for AMR containment
Roles of various stakeholders at state level
State Health Departments• Strengthen microbiology laboratories for quality assured surveillance of AMR
• Establish/Strengthen HMIS/LIMS for effective AMR data management
• Establish state level mechanism for collection and analysis of AMR data from all
laboratories in the state
• Infection prevention and control practices in healthcare and in community
• Ensure availability and maintenance of infrastructure, resources, services and practices for
efficient hygiene and sanitation in all health care facilities
• Strengthen implementation of regulations to eliminate substandard and spurious
antimicrobials and to prevent over the counter sale of antimicrobials
• Establish a state surveillance system and monitoring framework for antimicrobial use
• Raise awareness about AMR among general population, and educate key stakeholders in
human health including medical students, doctors, nurses, pharmacists, dental
professionals
• Establish antimicrobial stewardship programmes to promote appropriate use of
antimicrobials through education and training in healthcare settings and in community
Department of Agriculture & Animal Husbandry
• Establish AMR surveillance in animals and food by strengthening laboratory
capacity for quality assured AMR surveillance
• Raise awareness of AMR among veterinary professionals, farmers, food suppliers
& industry
• Infection prevention and control practices in animals and food
• Establish intersectoral coordination for regulation of use of antimicrobials in food
animals
• Establish surveillance of antimicrobial use in animals, food and agriculture
• Improve appropriate use of antimicrobials in animals and agriculture
• Restrict use of critically important antimicrobials in animals & fisheries and
agriculture
Department of Environment, Forest & Climate Change
• Establish and strengthen capacity of laboratories for quality assured surveillance of AMR
and antimicrobial residues in the environment
• Implement national/state policies and strategies to reduce impact of AMR on the
environment
• Collaborate with other ministries to raise awareness of AMR among key stakeholders in
environment as well as other aspects of AMR
Drinking Water and Sanitation
• Ensure infrastructure, resources and services for sanitation and hygiene in the
community
• Ensure safe drinking water, free from microbes and antibiotic residues
• Reduce biological burden of infectious disease through community awareness on AMR
and hand hygiene
Information and Broadcasting
• Collaborate with other ministries to support development and dissemination of the
national/state campaign to raise awareness on AMR
• Collaborate with other key ministries to improve sanitation and hygiene to prevent
infections
Chemicals and Fertilizers
• Ensure uninterrupted access to quality assured and affordable antimicrobials
• Collaborate with MoHFW to ensure implementation of quality management
system for supply chain management of antimicrobials and
• Ensure effective implementation of regulations regarding antibiotic residues in
effluent from pharma industry
Food Processing Industries
• Ensure food safety by monitoring and eliminate presence of AMR and antibiotics in the food
industry in collaboration with FSSAI and DADF
Consumer Affairs, Food & Public Distribution
• Collaborate with other ministries to raise awareness about AMR and antibiotic residues in
food, and promote use of antibiotic free food, especially from dairy, poultry, meat and
fisheries
Finance
• Estimate and review investment needs in coordination with all stakeholders and
support budget allocation to different ministries/organizations
• Collaborate to develop the resource mobilization plan for sustainable action
Steps for the development of State action plan
• Mapping of AMR stakeholders in the State
• Compile the background document – AMR and its Containment in the State
• Organize a state workshop to develop state action plan for AMR containment
• Establish governance mechanisms for AMR containment in the state
• Implementation of state action plan
Challenges in NAP development and implementation
• Formation of independent National authority for AMR containment NACA (most essential and urgent first step), currently no allocated manpower,
• well represented from all stakeholders, • proper secretariat, • with adequate statutory powers (like FSSAI, FDA etc)
• Commitment/involvement of all stakeholder departments/ministries
• Funding for NAP-AMR activities
• National Coordinating Unit (NCU) for IPC
• Coordination with other stakeholder departments and ministries/ Intersectional coordination
• Development of State action plans and their implementation
• Defining which activities to be done at central level and which to be done at the state level
Way forward for AMR containment: human health
▪ Include AMR in curriculum of MBBS & allied courses, MCI minimum requirement to include 24hrs
microbiology lab services,
▪ Integrate Microbiology in patient management algorithms so as to ensure diagnostic stewardship and
adequate utilisation & funding of Microbiology laboratories.
▪ Expand AMR surveillance to district hospitals and private sector
▪ Strengthen Quality Assurance in labs
▪ Strengthen Data collection, Reporting, Analysis through mandatory HMIS/LIMS
▪ Synergize all AMR surveillance at one platform to be submitted to GLASS
▪ Expand the list of pathogens under AMR surveillance, including community data
▪ Promote implementation of IPC practices at all levels of health care facilities,
▪ Expand surveillance of health care associated infections – CAUTI, VAP, CLABSI, SSI
▪ Surveillance of antimicrobial use
▪ Regulate manufacturing & sale of diagnostics for infectious diseases & antibiotic discs to ensure
quality products sold in market
▪ Strict implementation of H1 regulation
• NACA /independent authority under MoF/Niti Ayog/PMO for implementation and monitoring of NAP-AMR
• Funding allocation for the activities from respective ministries/departments
• National Coordinating Unit (NCU) at MoHFW for implementation of IPC and HAI surveillance
• Dedicated manpower for monitoring implementation
Way forward for NAP-AMR implementation
Way forward for AMR Containment: Integrated One Health approach
• Surveillance of AMR and antimicrobial use in all sectors –human, veterinary, food and environment
• IEC activities for raising awareness about AMR• Strengthen sanitation, hygiene, infection prevention and biosecurity• Promote rational use of antibiotics• Stop use of antibiotics for growth promotion and prophylaxis in animals• Strengthen regulations in humans; and establish regulations for use of
antibiotics in veterinary and food sector; and for effluent treatment tosafeguard the environment
• Promote development of newer drugs, vaccines and diagnostics
Thank you