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