UAE National AMR Action Plan

UAE National AMR

Action Plan

Najiba M Abdulrazzaq

Internist

Head of medical department,

Al Kuwait Hospital Dubai

National AMR Committee Chair

pathways of transmission of resistant bacteria between animals, humans and the environment

1. water sanitation systems 2&3. use of animal manure on cultivated crops 4&5. Uptake and spread of resistant bacteria can occur through the food chain 6. water distribution infrastructure7. wildlife 8. tourism, migration and food imports (HAIs) At the healthcare facility level, resistant bacteria can spread by contact between patients or with healthcare staff, or through contaminated surfaces and medical devices

1. Improve awareness and understanding

of AMR

Risk

Communi-cation

Education

2. Strengthen knowledge

through surveillance and research

National AMR

surveillance

Laboratory capacities

Research and

development

3. Reduce the incidence of

infection through effective

hygiene & IPC

IPC in health care

Community level

prevention

Animal health:

prevention and control

4. Optimize the use of

antimicrobial medicines in

human & animal health

Access to qualified

antimicrobial

medicines, regulation,

AMS

Use in veterinary

and agriculture

5. Ensure sustainable investment

through research &

development

Measuring the burden

of AMR

Assessing investment

needs

Establishing procedures

for participation

Global Action Plan: Priority areas

• Strengthening surveillance and monitoring, and moving towards national ‘One Health’ surveillance systems

• Limiting the exposure of antimicrobial-resistant pathogens to the environment

• Fostering R&D of new antimicrobial therapies, diagnostics and vaccines

Relevant Stakeholders• Federal Ministries

• Ministry of Health and Prevention (MOHAP)• Ministry of Presidential Affairs (MOPA)• Ministry of Climate Change and Environment (MOCCE)

• Regional Health Authorities• Department of Health Abu Dhabi (DoH)• Dubai Health Authority (DHA)

• Regional Animal/food authorities• Abu Dhabi Food Control Authority• Dubai municipality

• Universities• United Arab Emirates University (UAEU)• Gulf Medical University (Ajman)

• Private sector

SWOT Analysis• More than 60% of facilities

have international accreditation

• Report to GLASS• Test food for Pathogenic

organism, imported food tested for AB residue

• Hospital standard mandate IPC and soon ASP

• No antibiotic dispensing without a prescription

• Many facilities with strong ASP&IPC

• Population mainly expats• Sustainability is a issue• Different cultures and

health background to deal with• Research and SDG

encouraged

• No national reference lab• Data mainly Abu Dhabi and

Dubai• Limited AMR surveillance in

animal• No national coordination

for IPC nor ASP• ASP is still fragmented in

hospitals• Need to audit

implementation

Strategic Plan

• Mandate has been issued for national AMR

committee that is multisectorial

• Political support achieved

• NAP AMR has been developed awaiting all sectors approvals

• Collaboration between human sector, food, animal and environment

• Budget to be allocated

AMR Education and awareness

• School

• Universities

• Healthcare workers

• Veterinarian, food and environment

• Public

1. Improve awareness and understanding

of AMR

Risk

Communication

Education

Healthcare workers Education

• Create a platform for broadcasting all the activities of the different axes of the AMR NAP- soon on MOHAP website

• Mandate for basic AMR education for all hospital staff in human, veterinary, food, agriculture and environment sectors upon employment and on yearly basis

• AMR Education will be requested for licensing and relicensing of health-related professions in human health, veterinary, food, agriculture and environment sectors

Awareness in Schools and Universities

• Ministry of Education to include AMR and Hygiene education in all school curricula

• Development of the core elements of AMR/Hygiene material to be included in school curricula

• Define the core components of educational material that should be included in different university curricula

AMR for Public Awareness• media material for all communication channels:

• TV/radio spots • Phone waiting time entertainment• SMS messages• Social media

• a year long schedule for broadcasting messages on national TV and Radio, social media (pop ups on Facebook, Instagram, etc.)

• Mandate from MOHAP to municipalities and from MOCCAE to farmers’ centers to do yearly mandatory session per each municipality or farmer center or ministry about AMR and hygiene

• Public figure associated with AMR awareness

2018 Awareness activities• Big Screen - the Emirates Airline Dubai Rugby Sevens:

• numbers of people each day who viewed19 000 on Thursday39 000 for Friday37 000 for Saturday

• Radio interview that was broadcasted every hour on the news updates

• 2 TV interviews for awareness in Public Programs

” sabah elkhair Dubai” on Dubai TV

and in News Update in Fujairah TV

• Dubai Frame was let in Blue for WAAW

• MOHAP social media were broadcasting messages.

Social media campaignAMR Campaign main objective was to grab quantitative data about UAE residents and citizens and their percentage of awareness about Antibiotic Resistance

Also, provide audience with medical facts and advices to raise their awareness about the seriousness of Antibiotic Resistance

How we reached our audience?

Total Reach Total Clicks

Total Questionnaire

Responses

~ 403.2 K ~ 5.8 K

377

Campaign Impact Overview

70%

30%

Male

Female

Social Media Campaign survey outcome

34%

63%

3% 20–30

31–49

50–70

180

75

122

BACTERIA

VIRUSES

ALL MICROBES

73%

27% Yes

No

103

43

231

STOP TAKING THE …

REDUCE THE DOSE …

COMPLETE THE …

If feel better after a few doses of the

antibiotics course?

Antibiotics are powerful medicines

that help to fight • About 52% have a false belief that antibiotics can

treat viruses or all microbes

• 73% knew that they should consult the physician

before taking an antibiotic

• 27% of the responders don’t consult physicians

• 61% complete the full antibiotics course

• 11% reduce the course without getting back to

physician

• 28% stop antibiotic course

Other activities

Total

Spots

Weekly Reach

Weekend Reach

~ 154 K

~ 246 K

10 Spots

Uni

Aim

Fatma college of health sciences

Raise awareness (AMR) and (ASP)

efforts among higher education

undergraduates and teaching

faculty in health sciences field.

Target

Audie

nce

FCHS faculty staff members and

pharmacy undergraduate students

Offered activities

1. Video presentation about AMR.

2. Oral presentations titled;

(Antibiotic Resistance: a Race Against

Time)

(Antimicrobial Stewardship Program

(ASP), Corniche Hospital Experience)

1. Antibiotics jeopardy game for

undergraduate pharmacy students

MBRUResearch project on

crisis of antibiotics usage in the UAEby 3rd Year MBBS student

41% of viral infections in 349 children received AB

Augmentin was the highest 35.6%

Radio Campaign

AMR surveillance• Organization of manpower to carry on the activities of AMR

surveillance axis in humans and animal

• Standardize AMR surveillance across all participating laboratories

• Stepwise capacity building plan for the hospitals that are not ready for inclusion in GLASS

• Generate local surveillance report that will direct professionals in putting local guidelines

• Generate a stratified surveillance report of data from:• Community vs. hospitals• Tertiary vs. primary care• Different Emirates

• Surveillance of the burden of AMR such as %HAI with MDROs

2. Strengthen knowledge through

surveillance and research

National AMR surveillance



UAE AMR Surveillance Sites: Geographical distributionEmirate Hospitals Clinics Total

SitesLabs

Abu Dhabi 25 53 78 12

Dubai 9 37 46 8

Sharjah 2 12 14 1

Ajman 4 -- 4 1

Um Al Quwain 2 -- 2 1

Ras Al Khaimah 5 16 21 2

Fujairah 1 4 5 1

Total 48 122 170 26

• All seven Emirates are represented in the UAE National AMR Surveillance System

• Private sector, and some Emirates (Dubai, Sharjah, Ajman) are still underrepresented

Surveillance Site (Hospital)

MZ

LW

MI

DL

SAGH

SKM

MQH

COH

NROYNSAD

MAN MAR

RAH

Abu Dhabi City (n=10)

Al Ain City (n=6)

WAGTWH

MAJMAA

CCAD DAE

Dubai City (n=9)

DH

IR

RH

ABHLH

NSAN NDIP

PR

AAH NSAA

FUJ

UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens Thompson, DoH

UAE AMR Surveillance: Key Resistance Rates, 2017Priority 1: CRITICAL*

Priority 2: HIGH*

Priority 3: MEDIUM*

*WHO, 2017 [1]. **UAE National AMR Surveillance, 2017 (not published). %Res = percent of isolates fully resistant

Priority 3: MEDIUM

Organism Antibiotic N (isolates) % Res

S. pneumoniae Penicillin G, non-susc. (I+R) 674 59.6

H. influenzae Ampicillin 761 9.3

Shigella spp. Fluoroquinolones 72 22.2

Priority: 2 HIGH


Enterococcus faecium Vancomycin 258 8.1

S. aureus MRSA 10,105 36.0

Salmonella spp. Fluoroquinolones (CIP) 624 18.9

Neisseria gonorrhoeae 3rd gen. Cephalosp. 51 0

Neisseria gonorrhoeae Fluoroquinolones (CIP) 73 74.0

Priority 1: CRITICAL


A. baumannii IPM or MEM 1,218 35.9

P. aeruginosa IPM or MEM 5,407 19.7

Enterobacteriaceae IPM or MEM 30,075 4.8

Enterobacteriaceae ESBL 16,917 31.3

United Arab Emirates (2017)**

Emergence of Carbapenem-resistant Enterobacteriaceae (CRE)Abu Dhabi, 2010-Q2/2018

48%

21%

21%

5%

3%

1%1%

K. pneumoniae

E. coli

Enterobacter spp.

Serratia spp.

Citrobacter spp.

Salmonella spp.

Proteus spp.

Morganella spp.

Providencia spp.

Pantoea spp.

CRE, by species

UAE National AMR Surveillance, 2017 [not published] courtesy of Dr Jens

Thompson, DoH

%NS (IPM or MEM)%R (IPM or MEM)%R (IPM and MEM)

% CRE

P. aeruginosa: Resistance to Carbapenems By Emirate

Abu Dhabi Ajman Dubai Fujairah RAK Sharjah UAQ

14.17.2

13.412.6 15.0

10.0

24.4

AJM

P. aeruginosa, percent of isolates with resistance to Carbapenems (%R,

Meropenem)

By Emirate, United Arab Emirates, 2017, N=5,879


Thompson, DoH

A. baumannii, percent of isolates with resistance to Carbapenems (%R, Meropenem)


A. baumannii: Resistance to Carbapenems By Emirate

Dubai


28.5

38.231.2 31.8

56.3 58.0 56.0

RAKUAQSHA


Thompson, DoH

Staph. aureus: Resistance to Oxacillin (%MRSA) By Emirate

Staph. aureus, percent of isolates with resistance to Oxacillin (%MRSA)


Dubai

RAK


37.8 33.931.4

35.3 37.8 35.6 34.6

Sharjah

Ajman

UAQ

FUJ

Abu Dhabi


Thompson, DoH

National reference laboratory

• Currently there is no NRL-AMR

• evaluation of the current situation for establishing reference lab(s) in the country to be guided by WHO EMRO

• Building laboratory capacity for all related sectors

• Proposed functions and required methods have been identified

• ADFCA has proposed to act as NRL for animal/food sector for AMR

• Collaboration between NAP steering committee, MOHAP and universities regarding research in AMR surveillance

Infection prevention and control• Establish IPC/AMR Department in MOHAP to

oversee all activities in all Emirates in all fields (human, veterinary, food and environment)

• Assigned focal points in different sectors of the country:

• climate change and environment

• human sector including the MOHAP, DoH, DHA and private

• Establish /adopt national IPC guidelines

• Capacity building for the personnel in charge

of IPC at hospital/emirate/national levels

Infection prevention and control

• Mandate that all healthcare staff have basic IPC training as pre-requisite for work

• Mandate from Ministry of Higher Education to include IPC in undergraduate training of nurses, physicians, veterinary care providers, and food handlers

• Universities to provide IPC diplomas or master’s programs and include IPC in research agenda

• licensing authorities to include IPC prerequisites (inclusive programs, on line training) for licensing & relicensing of health professionals

Infection prevention and control

• Mandate already published for IPC program for licensing and relicensing of hospitals

• IPC for in long term care facilities (LTCF)

• Adopt/adapt international or regional guidelines

• Conduct surveillance of HAI:• Process indicators:

• Hand Hygiene

• Bundles for SSI, CAUTI, CLABSI and VAP

• Outcome indicators:• SSI, CAUTI, CLABSI and VAP

Infection prevention and control in animal/food/environment• Establish inter-ministerial communication regarding

AMR and IPC

• Review and adaptation of biosafety legislation in veterinary world agriculture and food safety to cover all aspects of IPC

• Present a detailed report about the applied biosafety

• Monitoring of the application of biosafety laws and the identified gaps if any

IPC Programs at Designated HospitalsComponent MOHAP HAAD DHA

Availability of functioning IPC policy& SOPs

Availability of isolation units at tertiary hospitals.

Availability of guidelines for the protection of HCW from HAI

Availability of surveillance within high risk groups to detect cluster of HAI

Availability of designated IPC professionals in all tertiary hospitals.

Availability of system to regularly evaluate the effectiveness of IPC program

2.305

1.604

1.956

0.704

3.9

2.6

3

0

1

2

3

4

5

VAP CLABSI CAUTI SSI

2018 Result Benchmark

Indicator

2018

Result Benchmark

VAP 2.305 1.9

CLABSI 1.604 3.9

CAUTI 1.956 2.6

SSI 0.704 3

Healthcare associated Infections 2018

Ventilator Associated Pneumonia(VAP)

12.3

1.56

0

1.94

1.15

0

2.96

10.14

0

2.85

0 0

3.34

0

3.07

0

2

4

6

8

10

12

14

VAP Benchmark

1.9

Hospital 1 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7Hospital 2 Hospital 12Hospital 11Hospital 10Hospital 9Hospital 8 Hospital 14Hospital 13 Hospital 15

Central Line Associated Blood Stream Infection (CLABSI)

5.3

0.88

0

2.9

0.51

0 0 0

2.61

0.81

3.69

0.95

4.38

0

2.462.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6

0

1

2

3

4

5

6

CLABSI Benchmark

Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 Hospital 13 Hospital 14 Hospital 15

Urinary Catheter Associated Infection(CAUTI)

3.6

0.93

1.64

2.152.49

12.74

0.3

10.26

2.041.76

3.63 3.77

1

0

1.11

3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9 3.9

0

2

4

6

8

10

12

14

CAUTI BenchmarkHospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 Hospital 13 Hospital 14 Hospital 15

Surgical Site Infection(SSI)

0.74

0 0

1.63

0.24

0

0.64

0.43

0

0.680.8

0.21

0.94

0

2.09

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

0

0.5

1

1.5

2

2.5

3

3.5

SSI BenchmarkHospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Hospital 9 Hospital 10 Hospital 11 Hospital 12 Hospital 13 Hospital 14 Hospital 15

Antibiotic Stewardship

• National sub-committee represents different healthcare sectors including MOHAP, DoH, Abu Dhabi, DHA and private healthcare facilities, in addition to the veterinary, agriculture and environment

• ASP mandated (Abu Dhabi) – March 2016

• Promote self-governance by requiring strong commitment from hospital leadership offering support to ASP activities

• Legislation of ASP to be a requirement in licensing standards of hospitals

ASP

Infectious Diseases

Nursing

Pharmacy Clinical Microbiology

Infection Prevention and Control

Antibiotic Stewardship - hospitals

• Surgical antibiotic prophylaxis

• Mandate to hospitals to report to national AMR committee the KPI results of surgical antibiotic prophylaxis

• Develop national guidelines for common infections

• Surveillance of antibiotics use in humans

• Audit of baseline situation of ASP in hospitals and follow up

Prospective Audit with Intervention

and Feedback

Pre-authorization of antimicrobials

Facility Specific Clinical Practice

Guidelines

Optimizing Dosing of Antimicrobials

Rapid DiagnosticsComputerized

Clinical Decision Support

IV to PO Therapy Conversion

Education and Training

Antibiotic Stewardship – outpatient clinics

• outpatient clinics should participate in ASP activities related to outpatients

• provide outpatient clinics with National Guidelines for common outpatient ID

• ABX consumption or point prevalence

Antibiotic Stewardship – Animal/food sectors

• Laws for antibiotic use in animals

• Quantify and trend antibiotic use in the veterinary practice

• Improve the awareness of veterinarians and farmers on the use of antibiotic

• Submit a yearly list of educational activities about antibiotic use in animals and agriculture through the country and use of alternatives

• Encourage research about alternatives to antibiotic in animals

• To present the results of antibiotic residue in food to ASP committee

ASP survey in Government Facilities

54%

88%

42%

50%

62%

33%

42%

67%

33%29%

92%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6 Facility 7 Facility 8 Facility 9 Facility 10 Facility 11

54%

71%

96%

62.50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Facility 1 Facility 2 Facility 3 Facility 4

ASP survey in Private Facilities

Research

• Include IPC and ASP research in national research agenda

• Encourage Literature review of the impact of early diagnosis in ID and ASP on expenditure of antibiotics, length of hospitals stay and other hospital-related economics

• Conduct local studies on clinical and economic impact of ASP

515.3

382.4

247.5 235.4 240. 225. 230.

0

150

300

450

600

2009 2010 2011 2012 2013 2014 2015

DD

D/1

000 Inpatient

Da

ys

Trend In Inpatient Antibiotic Consumption 2009-2015

ASP IN Tawam Hospital

54% reduction in global use1. AED 4 million savings/year in direct drug cost alone2. Indirect benefits: Decreased LOS, better outcomes,

reduced resistance.

Carbapenem use fell by 57.7%

3rd&4th gen cephalosporin use by 74.8%

fluoroquinolone use by 90.5%

Courtecy of Dr Reyhan Hashimi

ASP in Al Baraha Hospital Dubai

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

May-1

5

Ju

ne-

15

Ju

ly-1

5

Au

gu

st-1

5

Sep

tem

ber

-15

Octo

ber-

15

Novem

ber

-15

Dec

emb

er-1

5

Jan

uary

-16

Feb

ruary

-16

March

-16

Ap

ril-

16

May-1

6

Ju

ne-

16

Ju

ly-1

6

Au

gu

st-1

6

Sep

tem

ber

-16

Octo

ber-

16

Novem

ber

-16

Dec

emb

er-1

6

Jan

uary

-17

Feb

ruary

-17

March

-17

Ap

ril-

17

May-1

7

Ju

ne-

17

Ju

ly-1

7

Au

gu

st-1

7

Sep

tem

ber

-17

Octo

ber-

17

Novem

ber

-17

DD

D/1

00

in

pa

tien

t d

ay

s

Piperacillin/ Tazobactam General

Consumption

Befor

eAfter

AS

0.00

2000.00

4000.00

6000.00

8000.00

10000.00

12000.00

14000.00

16000.00

18000.00

20000.00

Jan

-16

Feb

-16

Mar-1

6

Ap

r-16

May

-16

Ju

n-1

6

Ju

l-16

Au

g-1

6

Sep

-16

Oct

-16

Nov-1

6

Dec

-16

Jan

-17

Feb

-17

Mar-1

7

Ap

r-17

May

-17

Ju

n-1

7

Ju

l-17

Au

g-1

7

Sep

-17

Oct

-17

Nov-1

7

Co

st i

n A

ED

Month

Piperacillin/Tazobactam Monthly CostBef

ore

AS

After

AS17400 AED

3621 AED

ASP in Sheikh Khalifa Medical City

• Results: Among 386 patients analyzed, 206 were admitted in the preintervention and180 in the postintervention period

• Reduce 18% in total antimicrobial cost (P , 0.0001)

• 40% decrease in ICU length of stay (P 5 0.1)

• 33% decrease in overall hospital length of stay (P 5 0.03)

• 34% decrease in mortality (0.04) from preintervention to postintervention period

• Among those not seen by ID, there was a 39% decrease in cost among those not seen by ID(P , 0.0001)

Remember…. Antibiotics are a limited, precious resource

• Antibiotic resistance is happening now, and it’s happening here

• Antibiotic Resistance threatens to return us to the pre-antibiotic era

• We all have a role to play in preserving the effectiveness of antibiotics

• If we don’t all take action today …….

there may be no cure tomorrow…

Summary

• AMR is a problem in UAE as part of global problem

• National AMR committee has drafted a plan

• The Plan is based on WHO GAP AMR

and has one health approach

• The plan is in its final stages of being

a combined ministerial decree

• Together will fight AMR

References

• WHO Global Action Plan on AMR

• CDC Core Elements of Hospital Antibiotic Stewardship Programs

• guidelines on core components of infection prevention and control

• AD AMR Surveillance System, AD public healthcare facilities (SEHA), 2010-2016

Thank [email protected]

UAE National AMR Action Plan

Documents

Transcript of UAE National AMR Action Plan