National Action Plan on Antimicrobial Resistance

1. Improve awareness and understanding of antimicrobial resistance;

2. Strengthen knowledge through surveillance and research;

3. Reduce the incidence of infection;

4. Optimize the use of antimicrobial agents in health, animal and food sectors; and

5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions. 12 Steps in development and implementation

1. Establish a governance mechanism a. Establish a functional multisectoral coordinating group (MCG) b. Establish technical working group(s). c. Ensure participation of national focal points on AMR in the human and animal health and agriculture sectors.

2. Conduct thorough situational analyses a. Collect data and available information b. Analyse data c. Assess capacities and identify gaps, opportunities and threats.

3. Planning a. Define strategic priorities b. Elaborate an operational plan and budget c. Prepare a plan for monitoring and evaluation (M&E).

4. Initiate implementation a. Submit core documents for validation by appropriate national authorities b. Conduct activities

5. Conduct periodic reviews, and incorporate lessons learnt 13 Situational analyses and assessment The situation analysis: A robust situational analysis involves assessment and analysis of information on: 1. Current AMR-related activities and structures in the country. 2. Capacity and structures to conduct surveillance of antimicrobial use and resistance.

3. Description of existing surveillance systems. 4. Known rates, such as: - AMR burden, - Rate of multi-drug-resistant tuberculosis.

5. Perceptions and behaviour related to known drivers of AMR, such as: - Limited knowledge of the risk for AMR; - Inappropriate use of antibiotics in humans, animals and plants, including over- prescribing and dispensing; and - Incomplete treatment courses (patients who do not finish a full treatment course);

6. Antimicrobial use in: - Human health (in communities, hospitals, other health care settings and for specific conditions such as sexually transmitted infections, HIV infection, tuberculosis and malaria) - Animal health (companion animals, livestock, aquaculture, veterinary practice) - Animal production - Plant production and health - Other environmental settings, and - Other situations; 7. The availability of alternatives to antimicrobials, including vaccines and others. 8. The status of known factors that promote the emergence of AMR. 9. Current capacity of country systems to regulate and enforce regulations on antimicrobial use, including for HIV infection, tuberculosis, malaria, in veterinary medicine and in crop production; 14

10. Existence and enforcement of policies and legal frameworks on the use of and resistance to antimicrobial agents in human health, animal health, plant production, environment, trade and commerce, such as: - National and subnational laws - Multinational or international agreements, including regional agreements for AMR interventions, the global action plan, OIE standards 11. Relevant stakeholders, including active donors and implementation partners. The current situation in different sectors in the kingdom of Bahrain 15 Country response Governance Terms of reference for the national multisectoral coordinating group, and for a technical working group Introduction A governance mechanism is essential for coordinating national efforts to combat antimicrobial resistance (AMR). The governance mechanism should comprise a national multisectoral coordinating group (MCG), and/or technical working groups as needed. Where in the kingdom of Bahrain now we have the national antibiotic committee under the umbrella of the Supreme council for health Authority to act: The coordinating group should be given sufficient authority to ensure that its recommendations and plans are implemented. Accountability: The group should be accountable to the lead minister or ministers or a senior executive function in the government. Dedicated funds: The availability of dedicated funds will increase the operational effectiveness of the group. Seed funds from external sources are often required initially, but government funds should be secured as early as possible to ensure political “ownership” and increase the likelihood of programme sustainability. Secretariat: Operational sustainability is more likely when sufficient dedicated personnel and funding are available to support administrative activities. 16 National multisectoral coordinating group Purpose The purpose of the national MCG is to oversee and, when necessary, to coordinate AMR-related activities in all sectors to ensure a systematic, comprehensive approach. It is recommended that the approach accord with defined AMR-related public health goals and with the global action plan for AMR.1 Scope The MCG should address all AMR-related activities in country. The scope should be broad enough to address all five strategic objectives of the global action plan, prioritizing activities in a step-wise approach. Role and responsibilities Leadership The MCG is expected to lead facilitation and, when appropriate, coordination of a national response to the threat of AMR. Its leadership could take the form of officially delegated authority, with more formal procedures and official monitoring, evaluation and reporting. Its role could be extended to making recommendations and progress reports and providing a platform for programme planning and implementation. Information sharing The MCG provides a structure for information-sharing to mutually reinforce activities among sectors. Facilitation and coordination The MCG should facilitate and, when appropriate and agreed, coordinate efforts to contain and reduce the threat of AMR at subnational, national and supranational levels. It is recommended that the MCG build a collaborative, cooperative, supportive environment for sharing knowledge, information and experience. Each participating party should understand the scope and limits of its own contributions and also its inter-dependence with other parties and with 17 the whole system in order to meet the defined goals. The difficulty of achieving such an environment and building such a system should not be underestimated. External interactions Collaboration with internal and external agencies and organizations is essential for many countries. Internal interactions A national AMR initiative must interact with the health system and public health and disease-specific programmes. The nature of these internal interactions and the results will depend on the country. As many agencies and programmes have responsibilities in areas affected by AMR, a guiding principle of the MCG is to find the most appropriate ways to facilitate and provide synergy with new or existing work so that the overall objectives of the programme are achieved. Membership The national MCG should be composed of members representing the relevant sectors, notably human health, animal health and production and the food and environment sectors. Representatives should be given sufficient authority by their institutions to make decisions. While it is important to have sufficient representation of these key stakeholders, the MCG should remain small enough to be functional, striking a balance between full representation and the functionality of the coordinating group. Meeting format and rules The meeting format and rules should conform to national norms. Standard operating procedures may be elaborated, transparently and according to the principles of best practice, to guide the activities of the coordinating group. The responsible minister(s) should select a chairperson on the basis of his or her expertise in leadership. Members should be selected to ensure that all relevant stakeholders are equitably represented. The stakeholders may be invited to propose members, but the chairperson (with the support of the secretariat) should ensure that the proposed members have sufficient skills, knowledge, authority and influence and can collaborate. It is advisable to achieve a gender balance. Consideration should be given to the duration of membership, with the objectives of balancing knowledge and experience with new ideas and maintaining representativeness while maximizing overall effectiveness. 18 If the MCG becomes too large or is given tasks that require specific expertise or input, it is often efficient to form either ad hoc or standing subgroups. Any subgroup should have a clearly defined mandate and an appointed chairperson. In addition, technical working groups can be established and mandated for tasks that include providing technical input for MCG decision-making. It is strongly recommended that the MCG be supported by an appropriately resourced secretariat responsible for the logistics of meetings; minute- taking; preparation and circulation of documents (e.g. background papers, reports and advisory notes to ministers); and storage and archiving. It is recommended that the group have a mechanism (with appropriate records) to ensure that its members have no conflicts of interests and that the work of the MCG in the interests of public health is transparent. Failure to ensure these elements could undermine the credibility and limit the effectiveness of the group. 19 Strategic plan, operational plan, budget, M&E plan Components of a NAP Summary of key components 1. Strategic plan - Goals and objectives - Priorities and interventions 2. Operational plan - Activities, implementation arrangements, timetable, responsible entities - Detailed budgeting and costing The following information should be provided for each activity and sub-activity at the beginning of each cycle and subsequently on a regular basis: - The dates or the period during which it will be implemented; - The setting in which it will be implemented; - The person, sector or institution that will be responsible for implementation; - The cost of implementation as calculated in the budget plan; - The source of funding to cover the cost; and - The indicator(s), milestones and targets that will be used to monitor implementation of the activity or sub-activity. The following information should be provided for each strategic intervention or activity: - If technical assistance is required, brief terms of reference, including specification of deliverables and the expertise needed to conduct the activities; - The entity responsible for implementation of the intervention or activity; - The timetable; - The estimated cost of technical assistance (including consultancy fee, travel, per diem) as calculated in the budget plan; - Source of funding, if available; and - The funding gap if there is no financial source to cover the cost of technical assistance.

3. Maintenance and evaluation plan - Performance indicators - Targets and timelines - Data collection and reporting methods 20 For each indicator of achievement of a goal, objective, strategic intervention or activity, the following elements should be specified:  The purpose of the indicator (input, output, outcome and impact);  The procedure used for calculation (e.g. absolute figure, proportion, ratio, rate, index);  The sources of information (for a rate, ratio or proportion, the sources of information for both the numerator and the denominator);  The periodicity (and timeliness) of data collection; and  The entity responsible for collecting the information. The program for hospitals; Summary of Core Elements of Hospital Antibiotic Stewardship Programs Leadership Commitment: Dedicating necessary human, financial and information technology resources. Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective. Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use. Action: Implementing at least one recommended action, such as systemic evaluation of on-going treatment need after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours). Tracking: Monitoring antibiotic prescribing and resistance patterns. Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff. Education: Educating clinicians about resistance and optimal prescribing. Elements of Antimicrobial stewardship program in the hospitals; I. An Antimicrobial Stewardship Management Team/Committee The key roles of the AMS management team/committee are to: •Ensure that evidence-based local antimicrobial guidelines are in place and reviewed regularly or when new evidence is published •Ensure regular auditing of the guidelines, antimicrobial stewardship practice and quality assurance measures •Report a regular formal review of the organisation’s retrospective antibiotic consumption data •Identify actions to address non-compliance with local guidelines, general antimicrobial stewardship issues and other prescribing issues. 21 II. Evidence-based antimicrobial prescribing guidelines The local antimicrobial stewardship policy should contain:

1. A policy statement that outlines the need for clear clinical case definitions and associated evidence of infection to minimise unnecessary prescribing of antimicrobials

2. Emphasize on the urgent need to start treatment with effective antibiotic agents for severe sepsis or life-threatening infections

3. A reminder for prescribers to use antibiotic agent(s) with an adequate spectrum to cover only the expected pathogens for less severe infections. To highlight that broad-spectrum antibiotics are sometimes not as potent in vitro as their narrower-spectrum counterparts against certain pathogens

4. A reminder for prescribers to consider the risk of resistant pathogens such as MRSA or ESBL-producing organisms and offer alternative treatment regimens accordingly or encourage prescribers to seek expert advice

5. A description of the importance of confirming the allergy status of recommended antibiotic agents in patients as there may be a need to offer alternative treatment choices for those who are allergic.

6. An outline for prescribers to take appropriate specimens for culture and sensitivity testing prior to commencing antibiotic treatment. However they should not delay starting treatment in patients with severe sepsis or life-threatening infections. 7. a recommendation for intravenous (IV) administration only to patients who are severely ill, unable to tolerate oral treatment, or where oral therapy would not provide adequate coverage or tissue penetration. 8. an outline for prescribers to review microbiology results daily and to de-escalate to pathogen-directed narrow-spectrum treatment promptly where appropriate. 9. a recommendation for prescribers to document the next review date or stop date and switch to the oral route of administration promptly in accordance with local IV-to-oral switch guidance. III. Antimicrobial prescribing guidelines should be guided by evidence and local susceptibility data (eg by area team where available). Guidelines should include the following:

1. Clinical diagnosis - to include: case definition, evidence of infection, severity assessment and relevant microbiology investigations

2. Recommendations for non-antimicrobial treatment (e.g. fluid resuscitation or surgery)

3. Empirical antimicrobial treatment recommendations: Initial antimicrobial therapy prior to availability of microbiology results or if a microbiological diagnosis is not going to be possible* 22

4. Directed antimicrobial treatment when microbiology results are known and advice to contact clinical microbiologists/infectious diseases specialists if required*

5. Oral switch guidance to highlight which oral agents to switch to and when

6. Duration of therapy for IV and oral agents

7. Specific guidance for exceptions and special cases if appropriate

8. Provide advice regarding monitoring and follow-up and contingency advice for treatment failure

9. Guidance for prophylaxis for surgery or procedures. These should also include: a. The aim of prophylaxis e.g. reduce surgical site infection, b. Where prophylaxis is required and where it is not, c. Distinction between risk groups e.g. patients colonised with multi-drug resistant organisms such as MRSA, ESBL and CRE, d. Alternatives where penicillin or other allergy exists and recommendation of single dose surgical prophylaxis regimens as appropriate and re-dosing frequency when more than one dose is required IV. Quality Assurance Measures/Audits and Feedback V. Education and Training SUSTAINING AN EFFECTIVE ANTIMICROBIAL STEWARDSHIP PROGRAM AND THE QAULITY INDICATORS TO BE REPORTED Process and outcomes measures to consider include: Quality indicators for the strategic plan (for 5 years): Clinical All-cause mortality Infection-related mortality Duration of hospitalization Rates of readmission Clinical cure (with or without precise definitions) 23 Microbiologic

1. Percent of organisms resistant to certain antimicrobial

2. Percent of multi-drug resistant organisms

3. Number of infections due to specified organisms

4. Rate of isolation of resistant organisms Usage Quantity of total antimicrobial use (e.g., in defined daily doses, days of therapy, or grams) Quantity of targeted antimicrobial use (e.g., in defined daily doses, days of therapy, or grams) Duration of therapy Percentage of oral vs. intravenous drug administration for agents with both oral and intravenous formulations Antimicrobial drug expenditures (demonstrate cost savings/neutrality) Compliance with surgical antibiotic prophylaxis Number of trained staff /sessions./ workshops Number of isolate suggested and their trend and patterns of resistance Cost in animals for antibiotic Rate for compliance with guidelines Number and type of interventions and/or recommendations made by the ASP Rates of clinician acceptance or implementation of ASP recommendations In primary care / outpatients’ clinics Total consumption of antibiotic per covered population In secondary care Ddd/ 1000 bed days or 1000 admission per year Dot per 100 bed days or 1000 admissions per year 24 In veterinary Total weight of antibiotics sold to be used Infectious disease Syndromes which there will be a national guidelines to measure the compliance with are the followings Skin and soft tissue infections Bacteremia / Candidemia Urinary tract infection Pneumonia (CAP/ HAP/VAP) Sepsis / septic shock Surgical prophylaxis Diabetic foot Endocarditis Upper respiratory tract infection 25 Strategic plan: Global action plan strategic objective 1: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. Awareness-raising and risk communication Objective 1 Increase national awareness of AMR Strategic interventions Activities 1.1. Establish an evidence-based public communications 1.1.1. Estimate awareness and knowledge through behavioural programme targeting audiences in human health studies in different social and professional groups. To conduct practice. researches in this field to study the awareness among public Milestone: April 2018 1.1.2. Conduct antibiotic campaign in the week of November 2018 1.1.3. Prepare materials for the media 1.1.4. Prepare educational materials for the public 1.1.5. Prepare program for the universities and schools 1.1.6. Establish awards for the best media and public education materials 1.1.7. To establish a website 1.1.8 to establish a newsletter 1.2. develop well-structured workshops for the health 1.2.1. To set a whole educational program or a full year care workers program for education for all health care workers 1.2.2. The program has to be tailored to all the subgroups 1.3.1. To prepare the materials for the public the suits , 1.3 develop educational session for the public written , newspapers , TV , social media 1.4 develop educational materials 1.4.1. Develop all educational materials for all sub categories Education Objective 2 Improve knowledge of AMR and related topics Strategic interventions Activities 26 2.1. Include AMR and related topics as a core component 2.1.1. Include AMR and related topics in undergraduate of professional education, training, certification and curricula for human health professionals, animal health development professionals and food industry and agriculture professionals Milestone: The educational programmes revised and 2.1.2. Prepare the materials for the undergraduate approved by June 2018 2.1.3. Get a focal point in MOE 2.1.4. Prepare a structured and certified program for undergraduate and students 2.1.5. To establish a program for E-learning Objective 3 Increase the number of research in the field of AMR Global action plan strategic objective 2: Strengthen the knowledge and evidence base through surveillance and research. Surveillance 3.1 to encourage members to conduct researches to establish a research agenda and train HCW to conduct research in the AMR Objective 4 Set up a national surveillance system for antimicrobial resistance Strategic interventions Activities 4.1. Establish a national coordination structure for 4.1.1. Write and approve terms of reference for a national surveillance of AMR. coordinating centre for AMR surveillance with the mandate to Milestone: by March 2018 oversee the AMR surveillance programme, including collecting, aggregating and sharing data. Objective 5 Improve laboratory capacity 5.1 Prepare training for microbiology laboratories 5.1.1. To prepare workshop for training for microbiology, Regarding the Rapid diagnostic testing, diagnostic markers with rapid test result on which the rational prescribing decisions and 27 appropriate measures for the prevention and control of infections are taken Objective 6 Build laboratory capacity to produce high-quality microbiological data for patient management and support surveillance activities in both human and animal sectors. Strategic interventions Activities 6.1. Designate a national reference laboratory for AMR 6.1.1. Write and approve terms of reference for a national surveillance. reference laboratory with expertise in methods for confirming Milestone: March 2018 and characterizing specific pathogens and organizing quality assurance schemes. 6.1.2. Establish a reference lab for AMR in animals 6.2. to prepare the list of the microorganisms that needs 6.2.1. To prepare the list to be reported with all the resistant pattern 6.3. to establish a program to link all the hospitals for 6.3.1. Communicate with WHO for training reporting or utilize the WHO-NET program 6.3.2. To work on establishing our program 6.4 to participate in GLASS program by WHO 6.4.1. To get training and starting the program in collaboration with WHO Objective 7 Strengthening the research capacity in AMR Research and development 7.1 to prepare a list of the gaps for research 7.1.1. Train and encourage HCW to conduct research in AMR March 2018 Objective 8 Identify operational research priorities for responsible use of antimicrobial agents and better practice in infection prevention in human and animal health Strategic interventions Activities 28 8.1. Prepare a national operational research agenda. 8.1.1. Engage relevant experts to identify current gaps in Milestone: July 2018 knowledge and potential research topics. 8.1.2.Training HCW in conducting research 8.1.3.Prepare a list of the gaps for research opportunities Global action plan strategic objective 3: Reduce the incidence of infection through effective sanitation, hygiene and prevention measures. Objective 9 Establish a national infection prevention and control programme Strategic interventions Activities 9.1. ensure proper development and use of infection 9.1.1. Ensure the presence of infection control teams in all prevention and control policies and strategies through hospitals. the focal points in the hospitals 9.1.2. Prepare training for all HCW Milestone: June 2018 9.1.3. Monitor surveillance data for HAI Objective 10 Introduce infection prevention and control programmes in veterinary settings and animal husbandry. Strategic interventions Activities 10.1. establish program for infection control in animal 10.1.2. Provide training health 10.1.3. Prepare core elements Milestone: June 2018 10.1.4. Audit the progress and quality indicators Objective 11 Limit the development and spread of AMR outside health settings by infection prevention and control. Strategic interventions Activities 11.1. Promote personal hygiene by social mobilization 11.1.1. Estimate knowledge of personal hygiene in different and behavioural change activities. social groups as a basis for the social mobilization campaigns. Milestone: March 2018 … Objective 12 Global action plan strategic objective 4: Optimize the use of antimicrobial medicines in human and animal health … 29 Global action plan strategic objective 4: Optimize the use of antimicrobial medicines in human and animal health. Regulated access to high-quality antimicrobial medicines Objective 12 Ensure uninterrupted access to high-quality antimicrobial medicines. Strategic interventions Activities 12.1. Strengthen the pharmaceutical supply chain, 12.1.1. Establish a quality management system for the supply including the procurement, supply and management of medicines, covering storage, transport, expiry date, system. distribution and disposal facilities with WHO standards. etc. Milestone: A quality management system introduced in all links of the supply chain by December 2018 12.2. Strengthen the supply of quality approved 12.2.1. Ensure that the national testing laboratory has the antimicrobials. capacity to test the quality of all antimicrobials used in humans. 12.2.2 Ensure that the national testing laboratory has the capacity to test the quality of all antimicrobials used in humans 12.2.3 Ensure that any adverse event or rejected batches after lab analysis will be reported based on pharmaco-vigilance systems. Antimicrobial stewardship Objective 13 Improve and measure appropriate use of antimicrobial agents in health care. Strategic interventions Activities 13.1. Create formal antimicrobial stewardship 13.1.1. Write generic terms of reference for antimicrobial programmes in health care facilities. stewardship multidisciplinary committees and teams. Milestone: Antimicrobial stewardship programmes 13.1.2. Establish the program in all the hospitals. established in 80% of acute care facilities by march 2018 13.1.3. To have all the core components of stewardship program in each hospital 30 13.2 Established the national guidelines for antibiotic use 13.2.1.To approve and disseminate these guidelines ( e.g. in human and animals. antibiotic surgical prophylaxis) 13.3 Establish a well-structured and approved 13.3.1. To develop a well-structured program for the educational program for health care workers and stewardship workers in animal sector. 13.4.1. To develop the quality indicators for process 13.4 Develop the quality indicators. ,outcomes and results 13.5 Unify the calculation methodology for antibiotic 13.5.1. To utilize the DDD/1000 PATIETNS DAYS / DOT PER usage in the health system. 1000 Patients days 13.6 To be part of the accreditation process and licensing 13.6.1. To work with NHRA for the process of accreditation of all hospitals through NHRA 13.7 Include the antibiotic stewardship training in all 13.7.1. To develop the program health sub speciality training e.g. physicians , nurses 13.8 Antibiotic stewardship research. 13..8.1. To be part of point prevalence studies 13.8.2. To conduct other studies 13.9 Develop syndromic guidelines for most common 13.9.1. Develop the guidelines and to be used with indicators disease to be used as a quality indicator. Use of antimicrobial agents in animal health and agriculture Objective 14 Ensure prudent use of antimicrobial agents in terrestrial and aquatic animals and agriculture. Strategic interventions Activities 14.1. Establish national policies on use of antimicrobial 14.1.1. Establish policies on the use of critically important agents in terrestrial and aquatic animals and agriculture. antibiotics. Milestone: June 2018 14.1.2. Get all the date about antibiotic use in animal sectors and monitor the amount and indications Global action plan strategic objective 5: Prepare the economic case for sustainable investment, ... and increase investment in new medicines, diagnostic tools, vaccines and other interventions. Objective 15 Prepare the economic case for sustainable investment in new medicines, diagnostic tools, vaccines and other interventions. 31 Strategic interventions Activities 15.1. Prepare a plan to secure and use financing for 15.1.1. Assess investment requirements for implementation of implementation of the AMR NAP. the NAP. Milestone: Assessment results available by May 2018 Operational plan and budget Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Strategic intervention 1.1. Prepare an evidence-based public communication programme for people in human health practice. Activity 1.1.1. Estimate awareness and knowledge through behavioural studies of different social and professional groups. Sub-activity 1.1.1.1 Awareness 2 April 2018 Nationwide National 1000 Supreme Baseline Measure AMR awareness in survey antibiotic Health awareness health care workers in the committee Council public sector. Post- interventio n awareness Sub –activity 1. 1..1.3. Number of the 5 April 2018 Nationwid National 5000 Supreme Number prepare materials for the educational e antibiotic Health done and media materials committee Council published Sub-activity 1.1.1.4 Number of the 5 April 2018 Nationwid National Supreme Number prepare educational educational e antibiotic Health done and 32 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) materials for the public materials committee Council published Sub-activity 1.1.1.5 Number to be 1 April 2018 Nationwid National Supreme Number prepare program for the prepared e antibiotic Health done and universities and schools committee Council published Sub-activity 1.1.1.6 Design awards 1 April 2018 Nationwid National 1000 Supreme establish awards for the best e antibiotic Health media and public education committee Council materials Sub-activity 1.1.1.7 Design a 1 April 2018 Nationwid National Supreme Number of to establish a website website e antibiotic Health times the committee Council website used Sub-activity 1.1.1.8 Design a 1 April 2018 Nationwid National Supreme Number of to establish a newsletter newsletter e antibiotic Health newsletter committee Council issued 1.2. develop well-structured workshops for the health care workers Sub-activity 1.1.2.1. to set a whole 1 April 2018 Nationwid National 1000 Supreme Number of to set a whole educational educational e antibiotic Health attendees program or a full year program committee Council program for education for all health care workers Sub-activity 1.1.2.2 to set a whole 1 April 2018 Nationwid National Supreme Number of the program has to be educational e antibiotic Health attendees tailored to all the subgroups program committee Council 1.3 develop educational session for the public Sub-activity 1.1.3.1 Number of the 1 April 2018 Nationwide National Supreme Number 33 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) to prepare the materials for educational antibiotic Health the public the suits , written , materials committee Council newspapers , TV , social media 1.4 develop educational materials Sub-activity 1.1.4.1 Number of the 1 April 2018 Nationwide National … Supreme develop all educational educational antibiotic Health materials for all sub materials committee Council categories Strategic intervention 2.1. Include AMR and related topics as core components of professional education, training, certification and development. Activity 2.1.1. Include AMR and related topics in undergraduate curricula for human health professionals, animal health professionals and food industry and agriculture professionals. Sub-activity 2.1.1.1 Prepare and 1 June Nationwide The national - Revised Revise undergraduate include it in the 2018 committee Supreme curriculum curriculum for medical curriculum MOE Health introduced doctors and nursing to Council incorporate AMR and related issues. Sub-activity 2.1.1.2. … … … … … … … … Sub-activity 2.1.1.4 Number of the 1 June Nationwid National … Supreme Number develop all educational educational 2018 e antibiotic Health materials for all sub materials committee Council categories Sub-activity 2.1.1.5 to establish a 1 June Nationwid National … Supreme Utilization 34 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) to establish a program for program for 2018 e antibiotic Health of the electronic learning electronic committee Council program learning Strategic intervention 3.1 Increase the number of research in the field of AMR Global action plan strategic objective 2: Strengthen the knowledge and evidence base through surveillance and research. Sub-activity 3.1 Researches to 1 … Nationwid National 10000 Supreme Number of to encourage members to be done e antibiotic health researches conduct researches committee council to establish a research Put the plan for 1 … Nationwid National … Supreme Number of agenda and train HCW to research e antibiotic health researches conduct research in the AMR committee council Strategic intervention 4.1. Establish a national coordination structure for surveillance of AMR. Activity 4.1.1. Write and approve terms of reference for a national coordinating centre for AMR surveillance with the mandate to oversee the AMR surveillance programme, including collecting, aggregating and sharing data. Sub-activity 4.1.1.1. National 1 March 2018 nationwide National Supreme National Prepare terms of reference coordinating committee health coordinati for a national coordinating centre terms of council ng centre centre for AMR surveillance. reference terms of reference ready for approval Sub-activity 4.1.1.2. … … … … … … … … Strategic intervention 5.1 Improve laboratory capacity 35 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Activity 5.1 Prepare training for microbiology Sub-activity 5.1.1 Worksop for 1 … Nationwide National 5000 Supreme Number of To prepare workshop for microbiology antibiotic health trained training for microbiology committee council personal Strategic intervention 6.1. Designate a national reference laboratory for AMR surveillance. Activity 6.1.1. Write and approve terms of reference for a national reference laboratory with expertise in methods for confirming and characterizing specific pathogens and organizing quality assurance schemes. Sub-activity 6.1.1.1. National 1 June 2018 nationwide The national Ministries National Develop terms of reference reference committee of health reference for a national reference laboratory and of laboratory laboratory. terms of agriculture terms of reference reference ready for approval Sub-activity 6.1.1.2. … … … … … … … … Activity 6.2. to prepare the list of the microorganisms that needs to be followed Sub-activity 2.2.1 To prepare the 1 March 2018 Nationwide The National - Supreme The list To prepare the list list Committee health council Activity 6.3. to establish a program to link all the hospitalized for reporting or utilize the WHO-NET program Sub-activity 6.3.1 Training 1 March 2018 Nationwid The national 5000 Supreme Number of communicate with WHO for through WHO e committee Health staff training Council trained Sub-activity 6.3.2 Establish a 1 March 2018 Nationwid The national Supreme Number of to work on establishing our program to e committee Health staff program train all the Council trained 36 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) hospitals Activity 6.4 to participate in GLASS program by WHO Sub-activity 6.4.1 Training 1 March 2018 Nationwide The national … Supreme Number of to get training and starting through WHO committee Health staff the program in collaboration Council trained with WHO Strategic plan 7.1 Improve the research capacity in AMR Activity 7.1 to prepare a list of the gaps for research Sub-Activity 7.1.1 Number of 1 March 2018 Nationwide The national As above Supreme Number of train and encourage HCW to researches committee Health researches conduct research in AMR Council march 2018 Strategic intervention 8.1. Prepare a national operational research agenda. Activity 8.1.1. Engage relevant stakeholders to identify the current gaps in knowledge and potential research topics. Sub-activity 8.1.1.1. Research 1 May nationwide The national Ministry of Draft prepare a list of the gaps that committees in 2018 committee health, research could be covered by research different public– agenda locations private developed partnership 37 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Sub-activity 8.1.2. Research 1 July 2018 Nationwid The - Supreme Number of training HCW in conducting committees in e national Health researches research different committee Council locations Sub-activity 8.1.3. Research 1 July 2018 Nationwid The - Supreme Number of prepare a list of the gaps for committees in e national Health researches research opportunities different committee Council locations Sub-activity 8.1.1.2. … … … … … … … … Strategic intervention 9.1 Establish a national infection prevention and control programme Activity 9.1. ensure proper development and use of infection prevention and control policies and strategies through the focal points in the hospitals Milestone: June 2018 Sub-activity 9.1.1 Infection 1 June 2018 Nationwide The national … Supreme Number of ensure the presence of control team committee Health staff infection control teams in all Council hospitals Sub-activity 9.1.2 Training in 1 June 2018 Nationwid The … Supreme Number of prepare training for all HCW Infection e national Health staff to be control committee Council trained Sub-activity 9.1.3. Surveillance 1 June 2018 Nationwid The … Supreme Surveillanc monitor surveillance data for data for HAI e national Health e data for HAI committee Council HAI 38 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Strategic intervention 10.1. Create a formal organizational structure at national level to ensure proper development and management of infection prevention and control policies and strategies. Activity 10.1.1. Write and approve terms of reference for a national infection prevention and control coordinating unit with authority delegated by a relevant administrative or political jurisdiction and an identified budget. Sub-activity 10.1.1.1. Terms of 1 May 2018 Nationwide The national - Supreme Infection Prepare terms of reference reference for committee Health prevention for a national infection an infection Council and prevention and control main prevention and control components . control unit unit terms of reference ready for approval Sub-activity 10.1.1.2 Provide training 1 June 2018 Nationwid The 5000 Supreme Infection provide training e national Health control committee Council training Sub-activity 10.1.1.3 Implement the 1 June 2018 Nationwid The - Supreme Infection prepare core elements core elements e national Health control committee Council training Sub-activity 10.1.1.4 Audit 1 June 2018 Nationwid The - Supreme Complianc audit the progress and quality e national Health e rate indicators committee Council Sub-activity 10.2 … … … … … … … … Strategic intervention 11.1 Limit the development and spread of AMR outside health settings by infection prevention and control Activity 11.1. Promote personal hygiene by social mobilization and behavioural change activities. 39 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Sub-activity 11.1.1. Infection 1 March 2018 Nationwide The national 1000 Supreme Survey Estimate knowledge of control in committee Health personal hygiene in different public Council social groups as a basis for the social mobilization campaigns Strategic intervention 12.1. Include hygiene and infection prevention and control unit as core (mandatory) content in training and education of veterinary professionals. Activity 12 Ensure uninterrupted access to high-quality antimicrobial medicines. Sub-activity 12.1.1. a quality 1 Dec 2018 Nationwide The national Supreme The Establish a quality management committee Health program management system for the system for the Council complianc supply of medicines, covering supply of e storage, transport, expiry medicines date, etc. Strategic intervention 13.1 Improve and measure appropriate use of antimicrobial agents in health care. Activity 13.1.1 Create formal antimicrobial stewardship programmes in health care facilities. Milestone: Antimicrobial stewardship programmes established in 80% of acute care facilities by march 2018 Sub –activity 13.1.1.1 antimicrobial 1 March 2018 Nationwid The - Supreme Number if Write generic terms of stewardship e national Health teams in reference for antimicrobial multidisciplinar committee Council all stewardship multidisciplinary y committees hospitals committees and teams. and teams. Sub-activity 13.1.1.2. antimicrobial 1 March Nationwid The - Supreme antimicrob establish the program in all stewardship 2018 e national Health ial the hospitals multidisciplinar committee Council stewardshi y committees p 40 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) and teams. multidiscip linary committee s and teams. Sub-activity 13.1.1.3. Develop the 1 March Nationwid The - Supreme The to have all the core core elements 2018 e national Health disseminat components of stewardship committee Council e the core program in each hospital elements Activity 13.2 established the national guidelines for antibiotic use in human and animals. Sub-activity 13.2.1 The national 1 March 2018 Nationwide The national - Supreme The To approve and disseminate antibiotic committee Health national these guidelines ( e.g. guidelines Council antibiotic antibiotic surgical guidelines prophylaxis) disseminat ion and implement ation Activity 13.3 establish a well-structured and approved educational program for health care workers and workers in animal sector Sub-activity 13.3.1 antimicrobial 1 March 2018 Nationwide The national - Supreme stewardship committee Health to develop a well-structured multidisciplinar Council program for the stewardship y committees and teams. Activity 13.4 develop the quality indicators. 41 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Sub-activity 13.4.1 To develop the 1 March 2018 Nationwide The national - Supreme Complianc to develop the quality quality committee Health e with the indicators for indicators Council indicators process ,outcomes and results Activity 13.5 unify the calculation methodology for antibiotic usage in the health system Sub-activity 13.5.1 to utilize the 1 March 2018 Nationwide The national - Supreme Complianc to utilize the DDD/1000 DDD/1000 committee Health e with the PATIETNS DAYS/ DOT PER PATIETNS DAYS Council DDD/1000 1000 Patients days / DOT PER 1000 PATIETNS Patients days DAYS / DOT PER 1000 Patients days Activity 13.6 to be part of the accreditation process and licensing of all hospitals through NHRA Sub-activity 13.6.1 Develop a plan 1 March 2018 Nationwide The national - Supreme The plan to work with NHRA for the with NHRA for committee Health process of accreditation accreditation Council requirements Activity 13.7 include the antibiotic stewardship training in all health sub speciality training eg physicians , nurses Sub-activity 13.7.1 Develop a plan 1 March 2018 Nationwide The national - Supreme The plan to develop the program with NHRA for committee Health accreditation Council requirements Activity 13.8 antibiotic stewardship research 42 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Sub-activity 13..8.1 to be part of 1 March 2018 Nationwid The - Supreme Number of to be part of point point e national Health hospitals in prevalence studies prevalence committee Council point studies prevalence studies Sub-activity 13.8.2 Number of 1 March 2018 Nationwid The Supreme Number of to conduct other studies studies e national Health studies committee Council Activity 13.9 develop syndromic guidelines for most common disease to be used as a quality indicators Sub-activity 13.9 develop the 1 March 2018 Nationwide The national Supreme Complianc develop the guidelines and to guidelines and committee Health e rate with be used with indicators to be used with Council guidelines indicators and reporting Strategic intervention 14.1. Promote personal hygiene by social mobilization and behavioural change activities. Activity 14.1.1. Estimate knowledge of personal hygiene in different social groups as a basis for social mobilization campaigns. Sub-activity 14.1.1.1. Knowledge 2 June Nationwide The national 2000 Supreme Baseline Estimate knowledge of survey 2018 committee Health data schoolchildren about Council personal hygiene. June 2019 Post- interventio n data Strategic intervention 15.1 Prepare the economic case for sustainable investment in new medicines, diagnostic tools, vaccines and other interventions. Activity 15.1.1 Prepare a plan to secure and use financing for implementation of the AMR NAP. 43 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) Sub-activity 15.1.1.1 Baselines 1 May 2018 Nationwide The national … Supreme Follow up Assess investment assessment committee Health requirements for Council implementation of the NAP. Strategic intervention 16.1. Create formal antimicrobial stewardship programmes in health care facilities. Activity 16.1.1. Prepare generic terms of reference for multidisciplinary antimicrobial stewardship committees and teams Sub-activity 16.1.1.1. Terms of 1 January nationwide The national Supreme Terms of Prepare generic terms of reference 2018 committee health reference reference for council ready for multidisciplinary approval antimicrobial stewardship committees. 16.1.1. Write generic Establish the 1 March 2018 nationwide The national Supreme The terms of reference for antibiotics committee health complianc stewardship council e with the antibiotic stewardship program with program program all its elements and the follow up 16.2 established the of the national guidelines for indicators antibiotic use in human and animals. 16.3 establish a well- structured and approved educational program for 44 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) health care workers and workers in animal sector 16.4 develop the quality indicators 16.5 unify the calculation methodology for antibiotic usage in the health system 16.6 to be part of the accreditation process and licensing of all hospitals through NHRA 16.7 include the antibiotic stewardship training in all health sub speciality training eg physicians , nurses 16.8 antibiotic stewardship research 16.9 develop syndromic guidelines for most common disease to be used as a quality indicators antimicrobial stewardship 45 Cost Responsible Source of Sub-activity Unit Quantity Date Location (currency Indicator entity funding ) multidisciplinary committees and teams. 16.10.establish the program in all the hospitals 16.11. to have all the core components of stewardship program in each hospital Activity 17.1. Assess investment required for implementation of the national action plan. Sub-activity 17 .1.1.. Assessment 1 May Capital The national Ministry of Assessmen Assess the investment report 2016 committee finance t report required, and identify gaps available for implementation of the NAP. Monitoring and evaluation plan Sample format with examples of indicators Planning element (activity Type and Value Frequency of Indicator Data source Method Baseline linked to the strategic plan) purpose (calculation) data collection 1.1.1. Measure awareness Level of Assessment, Awareness Baseline, Baseline Awareness Measured in and knowledge in different awareness by baseline scores stratified according to survey survey baseline social and professional survey, by target group schedule of report, post- 46 Planning element (activity Type and Value Frequency of Indicator Data source Method Baseline linked to the strategic plan) purpose (calculation) data collection groups. target group monitoring and (composite awareness- intervention survey evaluation of indicator) raising survey outcome campaigns reports (biannual) 2.1.1. Include AMR and Revised curricula M&E of input Yes/No Annually Key Key informant No curricula related topics in available for informant at interview with AMR No. of curricula undergraduate curricula for target ministry of and related / No. of professionals in human and professional the topics professional animal health, the food groups education groups to target industry and agriculture. 4.1.1. Write and approve National M&E of input Yes/No Annually Key AMR No terms of terms of reference for a coordinating informant at surveillance reference for national coordinating centre terms of ministry of programme national centre for AMR reference health implementatio coordinating surveillance. written and n report centre approved 6.1.1. Write and approve National M&E of input Yes/No Annually Key AMR No terms of terms of reference for a reference informant at surveillance reference for national reference laboratory terms ministry of programme national laboratory. of reference health implementatio reference written and n report laboratory approved 8.1.1. Engage relevant Draft research M&E of input Yes/No Annually Key Key informant No research experts to identify current agenda prepared informant at interview agenda gaps in knowledge and ministry of 47 Planning element (activity Type and Value Frequency of Indicator Data source Method Baseline linked to the strategic plan) purpose (calculation) data collection potential research topics. health 10.1.1. Write and approve Infection M&E of input Yes/No Annually Key Infection No terms of terms of reference for a prevention and informant at prevention and reference for national infection control unit ministry of control infection prevention and control terms of health programme prevention coordinating unit. reference implementatio and control written and n report unit approved 12.1.1. Include hygiene and Revised curricula M&E of input Yes/No Annually Key Key informant No curricula infection prevention and available for informant at interview with hygiene No. of curricula control in undergraduate target ministry of and infection / No. of curricula for animal health professional agriculture prevention professional professionals. groups and control groups targeted 14.1.1. Estimate knowledge Level of Assessment, Knowledge Baseline Baseline Knowledge Measured by of personal hygiene in knowledge of baseline survey scores stratified survey report survey baseline different social groups. target groups by target groups survey M&E of Post- (composite Biannually outcome intervention indicator) survey reports 16.1.1. Establish a quality Quality M&E of input Yes/No Annually Key Key informant No quality management system for the management informant at interview management medicines supply chain. system drug system established and regulation introduced agency 48 Planning element (activity Type and Value Frequency of Indicator Data source Method Baseline linked to the strategic plan) purpose (calculation) data collection 18.1.1. Write generic terms Antimicrobial M&E of input Yes/No Annually Key Key informant No terms of of reference for stewardship informant at interview reference for multidisciplinary committees ministry of antimicrobial antimicrobial stewardship terms of health stewardship committees and teams. reference committees written and approved 20.1.1. Prepare policies on Policies prepared M&E of input Yes/No Annually Key Key informant No policies use of critically important and introduced informant at interview antibiotics. ministry of agriculture 22.1.1. Assess investment Investment M&E of input Yes/No Annually Key Investment No required for assessment informant at needs assessment implementation of the NAP. available ministry of assessment finance report 49 References

1. Global action plan on antimicrobial resistance (English, French, Russian) http://www.who.int/antimicrobial-resistance/publications/global-action- plan/en/

2. Antibiotic resistance Fact Sheet 5 February 2018. http://www.who.int/en/news-room/fact-sheets/detail/antibiotic-resistance

3. Tackling Antimicrobial Resistance Together. Working paper 1.0: Multisectoral coordination http://www.who.int/antimicrobial- resistance/publications/workingpaper1multisectoralcoordinationAMR/en/

4. Tackling antimicrobial resistance (AMR) together. Working Paper 5.0: Enhancing the focus on gender and equity. https://www.who.int/antimicrobial-resistance/national-action-plans/workingpaper5enhancingthefocusongenderandequity/en/

5. Antimicrobial resistance: A manual for developing national action plans. http://www.who.int/antimicrobial-resistance/national-action- plans/manual/en/

6. Library of national action plans: http://www.who.int/antimicrobial-resistance/national-action-plans/library/en/

7. Country self-assessment questionnaire and guidance notes (Arabic, Chinese, English, French, Russian, Spanish). http://www.who.int/antimicrobial- resistance/national-action-plans/AMR-self-assessment-2016/en/

8. WHO competency framework for health workers’ education and training on antimicrobial resistance. Geneva: World Health Organization; 2018.

9. Global antimicrobial resistance surveillance system (GLASS) report. Early implementation 2016-2017

10. National antimicrobial resistance surveillance systems and participation in the Global

11. Antimicrobial Resistance Surveillance System (GLASS): A guide to planning, implementation, and monitoring and evaluation. EN: http://apps.who.int/iris/bitstream/10665/251554/1/WHO-DGO-AMR-2016.4-eng.pdf?ua=1

12. GLASS core components checklist and questionnaire. EN: http://apps.who.int/iris/bitstream/10665/251552/1/WHO-DGO-AMR-2016.5- eng.pdf?ua=1

13. Diagnostic stewardship: A guide to implementation in antimicrobial resistance surveillance sites. EN: http://apps.who.int/iris/bitstream/10665/251553/1/WHO-DGO-AMR-2016.3-eng.pdf?ua=1

14. Global Antimicrobial Resistance Surveillance System (GLASS) Manual for Early Implementation (Chinese, English, French, Russian, Spanish). http://www.who.int/antimicrobial-resistance/publications/surveillance-system-manual/en/

15. Emerging antimicrobial resistance reporting framework. https://www.who.int/glass/resources/publications/emerging-antimicrobial-resistance- reporting-framework/en/ 50