Info Service on Health Issues (Nov17/10)
Antimicrobial Stewardship in the Western Pacific and South East Asia Regions
The analysis below, which first appeared in HAIAP News, August 2017, is based on the antimicrobial stewardship (AMS) plans in countries in the abovementioned regions. The format and content of the national action plans (NAPs) of the identified countries were examined against WHO’s Global Action Plan template.
The study shows that all the NAPs were committed to the One Health model which promotes a multisectoral response to control antimicrobial resistance.
However there were variations in the interpretation of the template among the countries as countries addressed issues which were most relevant to them.
Analysis of AMR/AMS Plans in the Western Pacific and South East Asia Regions
Prepared by Beverley Snell and colleagues, HAIAP News August 2017
The United Nations General Assembly and the World Health Organisation have identified antimicrobial resistance (AMR) as a fundamental threat to human health and global health security. In 2014, the WHO’s Global Surveillance Analysis recognised alarming rates of resistance to essential antibacterial drugs among bacteria commonly associated with hospital and community acquired infections in each of the six WHO global regions. Rates of multi-drug resistance among previously treated Tuberculosis (MDR-TB) cases have risen to 20.2% in Eastern Europe and Central Asia, while the prevalence of artermisinin-resistant malaria infections is increasing globally.
A draft of the WHO’s Global Action Plan on AMR was put forward at the Sixty-eighth World Health Assembly in 2015, with the aim of ensuring continuity, accessibility and responsible use of existing treatments for infectious diseases.  These resolutions were supported by joint commitments from the World Organization for Animal Health and the Food and Agriculture Organization of the United Nations (FAO) in May and June of 2015, respectively. 
(Organisation, 2015 #58)
The WHO’s Global Action Plan calls for all WHO member nations to construct their own national plans by May, 2017. The WHO Global Action Plan provides a template as a guide for developing all components of the National Action Plans (NAPs) as well as a guide for the implementation plans that would be developed following the development of the NAPs.
Several national action plans in the WHO’s Western Pacific Region and South East Asia region were available on the WHO websites by early 2017. 
The format and content of the identified national action plans were examined against the WHO’s Global Action Plan template.
Western Pacific Countries
Seven of the 37 countries in the Western Pacific region with Plans available in English were Australia, Cambodia, People’s Republic of China, Fiji, Japan, Philippines and Vietnam. Cambodia’s National Policy to Combat Antimicrobial Resistance is supported by a partner document, the National Strategy to Combat Antimicrobial Resistance; for our purposes, the latter document has been viewed.
South East Asia countries
The WHO South East Asia Region has 11 Member States: Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste.
Countries with Plans available on the website are Bangladesh, Democratic Republic of Timor-Leste, India, Indonesia, Maldives, Nepal, Sri Lanka, Thailand.
The WHO guidance manual is here
WHO provided a 22 page sample template for a National Action Plan on Antimicrobial Resistance to assist countries in the development of their own Plans.
The template provides guidance for development of
· Executive summary
· Situation analyses and assessment
· Country response
Country responses could be developed under the following strategic objectives.
Strategic objective 1: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training.
Strategic objective 2: Strengthen the knowledge and evidence base through surveillance and research.
Strategic objective 3: Reduce the incidence of infection through effective sanitation, hygiene and prevention measures.
Strategic objective 4: Optimize the use of antimicrobial medicines in human and animal health
Strategic objective 5: Prepare the economic case for sustainable investment, ... and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Operational Plan of Activities Template
Following the guidance for the development of a strategic plan, the template included guidance for development of an operational plan of activities.
Most countries had followed the template format to a major extent but there is significant variation in the interpretation of the template. The Plans showed that countries addressed issues perceived to be most relevant for them. Australia, Fiji and Cambodia in the WPR and Bangladesh and Maldives in the SEAR were guided by the template to develop strategic plans that would be followed by detailed Operational Plans of Activities that would satisfy the Strategic Plans. The others incorporated action plans into their documents.
Commitment to the One Health model, which recognizes the interconnectedness of animals, humans and the ecosystem as contributing factors to AMR, and therefore promotes a multi-sectoral response, was demonstrated in all the national plans. Genuine involvement in the planning across all relevant sectors was demonstrated in most plans.
Ownership of the Plans
Ownership of the Plans among all ‘stakeholders’ would be important for successful implementation. A few countries had involved a group of Plan Developers from a fairly narrow range of health sector representatives while naming a wide range of representatives on their steering and implementing committees. Involving as many ‘stakeholders’ as possible in the development of the plan might result in stronger ownership.
The format of the plans
Those countries whose Plans were presented as Strategicplans, to be followed by operational plans of activities are difficult to compare with those that included activities for implementation.
Most of the plans that included activities could perhaps have been better conceived had activities been developed later by a dedicated body - to satisfy the needs of strategic plans. That would have enabled activities to be planned more precisely with identification of who is responsible and how the activity would be implemented, together with better outcome indicators.
Many, but not all, countries have undertaken studies that identify targets that need to be addressed by an AMR Plan but most countries have not completed a comprehensive situation analysis across all areas.
It is suggested that it could be a sound approach to develop the Plan as a Strategic Plan before developing an operational plan of activities. The strategic plan could identify areas needing more study and studies of identified areas could be built into the implementation plan along with other activities.
All plans committed to establishing and maintaining standardised antimicrobial stewardship (AMS) guidelines, programs and materials in hospitals. Australia extended this commitment to aged care and general practice settings, while China, Cambodia and Vietnam committed to AMS programmes in pharmacies.
All countries expressed a commitment to establishing, monitoring and improving surveillance and testing of AMR in human and animal healthcare settings, along with a universal commitment to ensuring adequate laboratory and research facilities. The less developed and smaller countries may not have the capacity to conduct testing to support surveillance and may need to establish links with reference laboratories in more developed countries.
In Thailand before the development of the plan, ineffective coordination meant that antimicrobial resistance profiles produced at sentinel hospitals were not used effectively for clinical decision-making. There was no integrated system for the surveillance of antimicrobial resistance, no system for monitoring consumption of antimicrobial drugs by humans, livestock and pets and little public awareness of antimicrobial resistance.
In August 2016, a national steering committee was formed to guide the plan’s implementation with a module to assess the prevalence of household antibiotic use and antimicrobial resistance awareness. A national system for the surveillance of antimicrobial consumption has also been initiated.
The countries from Western Pacific and South East Asia that had developed National AMR Plans had very diverse animal sectors. Japan, China and Australia have significant commercial livestock industries. Cambodia has increasing buffalo, pig and chicken industries; Vietnam has increasing dairy industry and extensive poultry farms with a history of bird flu infection. Thailand has identified in animals, resistant MRC-1 genes that can be traced to China. In December 2015 bacteria with the MRC-1 gene were also found in humans and in meat in England.
Indonesia has a significant commercial meat production industry. Poultry and goat farming exist in Maldives and Philippines has poultry, pig and cattle industries; while in Fiji and several other countries livestock farming is insignificant with most animals kept as ‘family’ animals. It is clear that plans need to be developed to address the specific needs in the sector. Plans indicate that most countries have identified their needs.
In the Philippines animal sector, excellent targets are identified against which to measure changes while in India there are large livestock industries with no regulatory control at all on the use of antibiotics and they have identified very poor documentation of antibiotic use and AMR in animals that must be addressed.
In May, ReAct Asia Pacific organized a one-day consultation entitled ‘Workshop on Anti-Microbial Resistance and use of Antibiotics in non-human sectors’ at Thiruvananthapuram, the capital city of the State of Kerala, India. The context for the workshop was set by Dr. B. Ekbal, HAIAP member and member of the State Planning Board.
The workshop attracted delegates from the government Departments of Animal Husbandry, Fisheries, Agriculture, Dairy Development and Environment as well as from large farms, government institutions, and two state universities. The following issues were discussed:
· Surveillance of antibiotic use and resistance in the fisheries sector
· Rational antibiotic use in fisheries sector
· Surveillance of antibiotic use and resistance in production of food animals
· Rational antibiotic use in production of food animals
· Surveillance in environment and agriculture.
The Directors of the Departments of Animal Husbandry and Fisheries gave assurances that the issue of antimicrobial resistance will definitely find a prominent place in the policies of their respective departments. Also, Dr Ekbal stated that he will include the issue of antibiotic resistance in the upcoming five year plan for the state. This is a significant step for a state with population of over 35 million
While factors needing attention were identified among health care providers, community members and industry, in some cases more detailed studies were needed to identify exact targets and provide a baseline. Several countries, for example Timor Leste, had undertaken significant situation analyses that guided their planned activities.
It is important to be able to identify where additional information gathering or audits are needed. It is equally important that recommendations from studies and audits are implemented promptly and the outcomes evaluated.
Although monitoring is built into most plans, addressing targets identified by monitoring is not always mentioned. It is expected that addressing targets as needed will be covered in further operational plans of activities. Several countries gave no attention to vaccination coverage against vaccine preventable infectious diseases in animals or humans.
Incentives and Morale
Incentives for health staff might encourage adherence to the plans and interest in achieving the goals. Including AMS components in mandatory continuing professional development to maintain their registration, would facilitate greater knowledge of the program and achievement of its goals.
Morale needs to be high so it is important that staff receive adequate support and recognition including adequate salaries.
Lines of Authority
Clear lines of authority need to be in place at all levels of the system so there is no doubt about who can make decisions or provide direction or support concerning activities to support AMS.
Almost all countries in the SEA region have plans. In the WP region many countries still have to develop plans. All countries with plans have demonstrated significant commitment to controlling AMR. Strong political commitment, national ownership and adequate multi-sectoral institutional capacities will be essential for the effective implementation of the national plans. A robust monitoring and evaluation platform must contribute to evidence-based interventions. An integrated system for the surveillance of antimicrobial resistance needs to be established.
You can find the available plans and their titles - to look at in detail - at the following links
Plans from countries
On the above page, the WHO web library includes, so far, the following:
Western Pacific Region
Australia 36 pages
Cambodia 19 pages Cambodia Strategy to Combat AMR-3 years 22 July 2014(FINAL).pdf
China 4 pages (link to Chinese language document)
Fiji 17 pages Fiji National AMR Action Plan.pdf
Japan 69 pages JAPAN_National Action Plan on Antimicrobial Resistance.pdf
Philippines 40 pages THE PHILIPPINE ACTION PLAN TO COMBAT ANTIMICROBIAL RESISTANCE.pdf
Republic of Korea National Action Plan on Antimicrobial Resistance (2016-2020).zip in Korean language
South East Asian Region
Bangladesh 12 pages
India 53 pages
Indonesia 56 pages
Nepal 24 pages
Sri Lanka 38 pages
Thailand 43 pages
 WHO. At UN, global leaders commit to act on antimicrobial resistance New York: WHO; 2016 [cited 2017. Available from: http://www.who.int/mediacentre/news/releases/2016/commitment-antimicrobial-resistance/en/
 WHO. Antimicrobial Resistance Global Report on Surveillance. Geneva, Switzerland: WHO; 2014.
 WHO. Global Action Plan on Antimicrobial Resistance. Geneva: WHO; 2015. p. 28.
 Resolution 26: Combating Antimicrobial Resistance and Promoting the Prudent Use of Antimicrobial Agents in Animals. Paris: OIE; 2015; Status Report on Antimicrobial Resistance. Rome: FAO; 2015.
 Library of national action plans Geneva: WHO; 2017 [Available from: http://www.who.int/drugresistance/action-plans/library/en/.