Finland National Action Plan on Antimicrobial Resistance 2017-2021

1. Training and education .................................................................................................................................... 19 1.1. Training of professionals........................................................................................................................................... 19 Current situation.................................................................................................................................................... 19 Objectives ................................................................................................................................................................ 19 Actions ................................................................................................................................................................... 20 1.2 Education of the general public........................................................................................................................ 21 Current situation.................................................................................................................................................... 21 Objectives ................................................................................................................................................................ 22 Actions ................................................................................................................................................................... 22

2. Nationally coordinated One Health surveillance ....................................................................... 24 2.1 Surveillance of antimicrobial resistance ................................................................................................... 24 Current situation .................................................................................................................................................. 24 Objectives ................................................................................................................................................................ 26 Actions ................................................................................................................................................................... 26 2.2 Surveillance of antimicrobial use..................................................................................................................... 29 Current situation.................................................................................................................................................... 29 Objectives ................................................................................................................................................................ 31 Actions ................................................................................................................................................................... 31

3. Preventing infections and controlling the spread of multidrug-resistant bacteria ....................................................................................................................... 34 3.1. Preventing infections ................................................................................................................................................... 34 Current situation.................................................................................................................................................... 34 Objectives ............................................................................................................................................................... 35 Actions ................................................................................................................................................................... 35 3.2. Combat of multidrug-resistant bacteria ................................................................................................... 36 Current situation.................................................................................................................................................... 36 Objectives ................................................................................................................................................................ 37 Actions ................................................................................................................................................................... 38

4. Guidelines on antimicrobial use for professionals ................................................................. 40 Current situation.................................................................................................................................................... 40 Objectives ................................................................................................................................................................ 41 Actions ................................................................................................................................................................... 42

5. Research .................................................................................................................................................................... 45 Current situation.................................................................................................................................................... 45 Objectives ................................................................................................................................................................ 46 Actions ................................................................................................................................................................... 46

6. Administrative structures .............................................................................................................................. 48 Current situation.................................................................................................................................................... 48 Objectives ................................................................................................................................................................ 49 Actions ................................................................................................................................................................... 50 Follow-up of the implementation of the Action Plan ........................................................... 51 References .................................................................................................................................................................... 52 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 ABSTRACT Antimicrobials, in other words antibiotics, are among the most significant inventions in medicine. Antimicrobial resistance, meaning that the microbes become resistant to anti- microbial medicines, is a global health threat to both humans and animals. Therefore, the actions to combat antimicrobial resistance were placed on the agenda of the UN General Assembly agenda held in autumn 2016. This is only the fourth time that a health issue has been addressed by the UN General Assembly. The action to combat antimicrobial resist- ance must be a joint effort at every level of society. The action must involve both humans, animals, foodstuffs and the environment. Attention must be paid to the identification of resistant microbes, the prevention of their spreading and prevention of infections but we must also ensure that antimicrobials are used correctly and responsibly in the treatment of humans and animals. No antimicrobials are used in Finnish plant agriculture but this is not the case globally. For this reason, the use of antimicrobials in plant production must also be taken into consideration as one further factor of increased resistance. The surveillance of antimicrobial resistance is a way to measure the efficacy of the preventive actions and to detect new threats. Antimicrobial resistance is a global, cross-border health threat calling for unrelenting preparedness and a maintained good level of control. It is vital that the reaction to new threats is rapid. This National Action Plan describes current situation to combat antimicro- bial resistance in Finland. The proposed recommendations for action focus on remedies to the recognised shortcomings, and suggest actions to enhance the various areas of antimi- crobial resistance control in the future. 9 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Table 1. Major actions by areas of operation Area of operation Major action Training of professionals and • Marked increase in communication and education on the significance of tourism for the educating the public spreading of antimicrobial resistance. • Support for further training in antimicrobial resistance control provided to social care and healthcare professionals as well as veterinary professionals and animal producers Nationally coordinated One • Develop real-time notification and reporting system for extremely resistant Health surveillance antimicrobial bacteria to support the exchange of information at the local, regional and national levels with the aim of enhancing appropriate control actions. • Build up an information system to collect animal species-specific usage data on antimicrobials. • Develop statistics and IT systems on antimicrobial use to allow for an itemised analysis of antimicrobial consumption data of hospitals and long-term care facilities. Prevention of infections and cont- • Preparing national recommendations for infection prevention at hospitals and long- rolling the spread of multi-resis- termcare facilities. tant bacteria • Produce guidelines on the prevention of infections caused by work-related resistant bacteria of animal original and draft joint operational principles for health and environmental health professionals to investigate and control the incidence of human diseases caused by resistant bacteria of animal origin. Guidelines for professionals on • Prepare an antimicrobial manual for outpatient healthcare to cover choices, dosage antimicrobial use and course duration of antibiotics used in the treatment of usual infections treated in outpatient care. • Set national objectives for volume of antimicrobial use in animal. Research • Propose basic and applied research programmes related to antimicrobial resistance and infectious diseases and support domestic and international networking of researchers in the field. Administrative structures • Enhance administrative cooperation across and between sectors and stakeholders by consolidating the operations of the national expert group (MTKA) through, for example, a legislative decree. 10 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Experts contributing to the Plan of Action Antti Hakanen, Chief Physician, Hospital District of Southwest Finland Jari Jalava, Senior expert, National Institute for Health and Welfare Liisa Kaartinen, Senior inspector, Finnish Food Safety Authority Evira Anni Virolainen-Julkunen, Ministerial Counsellor for Health and Medical Affairs, Ministry of Social Affairs and Health Sari Ekholm, Senior Medical Officer, Ministry of Social Affairs and Health Nina Kaario, Senior Veterinary Officer, Ministry of Agriculture and Forestry Eeva Nurmi, Ministerial Adviser, Ministry of the Environment Outi Lyytikäinen, Research Professor, National Institute for Health and Welfare THL Pekka Eränkö, Senior Medical Officer, Finnish Medicines Agency Fimea Terhi Laaksonen, Head of Unit, Finnish Food Safety Authority Evira Anna-Liisa Myllyniemi, Head of Research Unit, Evira Asko Järvinen, Senior Medical Officer, Helsinki and Uusimaa Hospital District HUS Mari Kanerva, Ward Chief, HUS Tea Nieminen, Specialist, HUS Jaana Syrjänen, Ward Chief, Tampere University Hospital TAYS Reetta Huttunen, Assistant Chief, TAYS Risto Vuento, Senior Medical Officer, Fimlab Maija Rummukainen, Senior Medical Officer, Kuopio Region Central Hospital KSKS Maarit Wuorela, Ward Chief, City of Turku Jane Marttila, Senior Medical Officer, City of Turku Tiina Kurvinen, Infection Control Nurse, Hospital District of Southwest Finland Anu Kantele, Professor, University of Helsinki Jaana Vuopio, Professor, University of Turku 11 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Abbreviations, definitions and translations of the special vocabulary AmpC Class C beta lactamase AMR Antimicrobial resistance, antibiotic resistance Avohilmo System of treatment notifications in primary healthcare, outpatient care Biosecurity, farms Modes of operation to reduce the spreading of infectious animal diseases in animal production Codex Alimentarius International food standards, recommendations and guidelines adopted by the Codex Alimentarius Commission founded by FAO and WHO in 1963. Colonisation The microbe settles and grows in the normal microbial flora (e.g., of humans) without causing any signs and symptoms. CPE Carbabenemase-producing Enterobacteriaceae EAAD European Antibiotic Awareness Day EARS-Net European Antimicrobial Resistance Surveillance Network ECDC European Centre for Disease Prevention and Control EFSA European Food Safety Authority ELTDK Faculty of Veterinary Medicine EMA European Medicines Agency ESAC-Net European Surveillance of Antimicrobial Consumption Network ESBL Broad-spectrum beta lactamase ESVAC European Surveillance of Veterinary Antimicrobial Consumption ETT Eläinten terveys ry (Animal Health Association), with the mission including the promotion of production animal health and wellbeing by coordinating the national animal healthcare and by steering the importation of animal materials and feeds in a way to control risks of disease. ETU National animal healthcare operations, managed by ETT and the Finnish Food Safety Authority Evira EU European Union EUCAST European Committee on Antimicrobial Susceptibility Testing Evira Finnish Food Safety Authority FAO Food and Agriculture Organization FiRe Finnish Study Group for Antimicrobial Resistance Finres National surveillance report on antimicrobial resistance (humans) FINRES-Vet Finnish Veterinary Antimicrobial Resistance Surveillance and Consumption of Antimicrobial Resistance GLASS Global Antimicrobial Resistance Surveillance System JPIAMR Joint Programming Initiative on Antimicrobial Resistance MDR-Aci Multidrug-resistant Acinetobacter MDR-Pseud Multidrug-resistant Pseudomonas MDR-TB Multidrug-resistant Mycobacterium tuberculosis 12 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 MMM Ministry of Agriculture and Forestry MRSA Methicillin resistant Staphylococcus aureus MTKA National expert group of antimicrobial resistance control One Health Joint health; notion combining human, animal and environmental health OIE World Organisation for Animal Health OKM Ministry of Education and Culture OPH Finnish National Agency for Education Prudent use of Antimicrobials are used for the treatment of infections on medical and veterinary grounds, in order antimicrobials to minimise their adverse effects. (See Area of operation 4). SEP ry Suomen Eläinlääkäripraktikot ry, Association of Finnish Practicing Veterinarians SIRO Hospital infection programme STM Ministry of Social Affairs and Health TEKES Finnish Funding Agency for Innovation TEM Ministry of Employment and the Economy TEY ry Association of Production Animal Veterinarians THL Institute for Health and Welfare TTL Finnish Institute of Occupational Health TTR Register of communicable diseases UN United Nations, UN VRE Vancomycin-resistant Enterococcus WHO World Health Organization VNK Prime Minister’s Office YM Ministry of the Environment Zoonosis Name for infectious diseases common to humans and animals 13 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Aim Antimicrobials, in other words antibiotics, are among the most significant inventions in medicine. They save human lives and have made modern medicine and veterinary med- icine possible. Antimicrobial resistance, meaning that the microbes become resistant to antimicrobial medicines, is a global health threat to both humans and animals. The aim of this Plan of Action is to maintain antimicrobial medicines efficacious in Finland. 14 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Structure of the Action Plan The control of antimicrobial resistance calls for extensive operations comprising society as a whole, taking both humans, animals, plants, foodstuffs, and the environment in- to consideration in line with the One Health approach. In the Plan of Action, the control of antimicrobial resistance is discussed both separately from and together with human healthcare, animals and foodstuff safety and the environment. The Action Plan compris- es six operative areas that are vital to the control of antimicrobial resistance: 1. Training of professionals and education of the general public; 2. nationally coordinated of One Health surveillance, including the surveillanceof antimicrobial resistance and use of antimicrobi- als; 3. prevention of infections and control of spreading of multi-resistant bacteria; 4. guid- ance for the use of antimicrobials; 5. research; and 6. administrative structures. The Plan of Action describes the current situation in all areas of operation, sets objectives and records actions to achieve the objectives. The responsible parties for each action are presented. In addition, the Plan of Action will include a model for the follow-up of the implementation of the actions. Some of the proposed actions cover several areas of operations. 15 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Background In autumn 2016, the actions to combat antimicrobial resistance were placed on the agen- da of the UN General Assembly. This is only the fourth time that a health issue has been addressed by the UN General Assembly. Antimicrobial resistance has reached such global dimensions that immediate action is required if we want to retain the efficacy of antimi- crobials. When bacteria, viruses or fungi become resistant to antimicrobials, it becomes increasingly difficult to treat the infections they cause, the courses of therapy become longer and, in the worst-case scenario, infection-related mortality increases. According to estimates, about 10 million people will die in 2050 due to infections caused by antimicro- bial resistant microbes unless we are able to curb the growth of antimicrobial resistance (1). The increase in antimicrobial resistance also has remarkable financial consequences. Pro- ductivity will decrease with rising morbidity. Costs will grow due to expensive therapies and, for example, increasing needs to isolate patients. Antimicrobial resistance will also worsen animal health, lowering productivity and raising costs, and will increase the num- ber of resistant bacteria transferring from animals and foodstuffs to humans. Antimicrobial resistance has also been included in the list of the top 20 major future risks of the World Economic Forum (2). By 2050, the cumulative costs caused by antimicrobial resistance will, according to certain estimates, amount to USD 108 million. Antimicrobial resistance develops when the microbes adapt and start to grow despite the presence of antimicrobials. The resistance is in direct connection to the quantity and frequency of antimicrobial use. When they end up in the environment, the antimicrobi- als cause the same selection of resistant microbes as takes place in humans and in ani- mals. Therefore, the development of resistance and the spreading of resistant microbes is a concern for our entire living environment. Resistant microbes circulate in the human and animal populations through physical contact, foodstuffs, water and the environment. They do not respect any boundaries and move easily from one country to another carried by humans, animals and foodstuffs. Antimicrobial resistance is a significant cross-border health threat. 16 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Comprehensive action is needed to control antimicrobial resistance. These actions can be classified in two categories: preventing the selection of resistant microbes on the one hand and preventing their spread on the other hand. The selection of resistant microbes is influenced by the use of antimicrobials. Reducing the overall consumption of antimicro- bials and using them in a prudent manner will decrease the selection pressure and there- by the risk for the inducing resistance in microbes. The means to promote prudent use of antimicrobials include, above all, guidance and the utilisation of microbiological diagnos- tics. The prevention of infections, in turn, decreases the need for the use of antimicrobials. One good example is provided by the vaccination programmes which can reduce the in- cidence of infections of the respiratory tract, in turn resulting in a diminished need to use antimicrobials. Prudent use of antimicrobials, microbiological diagnostics and the preven- tion of infections through biosecurity measures, vaccinations and other measures are also key issues in veterinary medicine and animal production. The prevention of the spreading of resistant microbes is the other cornerstone in the com- bat of antimicrobial resistance. This applies primarily to various healthcare facilities but it also includes the prevention of population-level colonisation. On the population level, tourism has become a significant factor in the spreading of resistant microbes. Here, the control measures are not only targeted at the prevention of infections but also and specif- ically at the prevention of the population-level colonisation. Public instruction and advice measures play a key role. Controlling the spread of resistant microbes also involves ani- mals and food production. Novel antimicrobials provide one means to solve the resistance problem. Development of medicines is vital but also extremely expensive and slow. It is of primary importance for the steering of antimicrobial use to develop real-time, easy-to-use and reliable microbio- logical tests that would allow for faster and improved diagnostics of infectious diseases. Finland has both traditional know-how and industry in this sector. The surveillance of antimicrobial resistance is a way to measure the efficacy of the preven- tive actions and also to identify new threats. In turn, the surveillance of antimicrobial use is a way to measure the adherence to the instructions and the functioning of the antimicro- bial policy. The surveillance systems provide us with comparable information on our situa- tion compared with the rest of the world. 17 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Assignment The resolution n. 67.25 of World Health Assembly requires the Member State to take ur- gent action to control antimicrobial resistance (3). WHO has published a Plan of Action (4) and instructions for the drafting of national plans of action (5). The Global Health Security Agenda also highlights the issue of antimicrobial resistance (6). The World Organisation for Animal Health (OIE) has issued its own recommendations (7). The European Union re- quiresthe Member States to take action to control antimicrobial resistance, and the EU has prepared its own plan of action (8). These recommendations are here presented in a table in Appendix 1. In Finland, the first cross-administrative (STM and MMM) recommendation on the control of antimicrobial resistance and the development of antimicrobial policies was published in the spring of 2000 (9). The Action Plan now prepared has taken the con- tents of all earlier recommendations issued by various organisations into account. 18 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Areas of operation

1. Training and education 1.1. Training of professionals Current situation No survey has been carried out on the training related to antimicrobial resistance in Fin- land. There is no specific training programme focusing on the issue but the topic is taught in the basic training of physicians, dentists, veterinarians and nurses. Antimicrobial resist- ance and its control are often on the agenda of various national training events organ- ised by various parties. Moreover, it is possible to focus more profoundly on the issue in specialisation training provided in different fields. There is no national coordination of the training programmes. It is not clear how well aware the healthcare professionals and vet- erinarians are of the antimicrobial resistance and the actions to impact the spreading of the phenomenon. Likewise, there is no information as to how much social welfare actors and animal keepers and owners know about these issues. Objectives Increase the knowledge among social care and healthcare professionals, veterinarians as well as animal keepers and attendants about antimicrobial resistance, the development of the resistance as well as the actions to impact the spreading of resistance. Improve the provision of information on the resistance situation. 19 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Actions General

1. Include antimicrobial resistance training in professional basic studies, including training on how the use of antimicrobials can be decreased through the use of other therapies and pharmaceuticals. Responsibility: STM, MMM, OKM, the parties and training units responsible for the competence requirements of training programmes.

2. Support for continuous training in antimicrobial resistance control provided to social care and healthcare as well as veterinary professionals and animal hus- bandry operators. Responsibility: STM, MMM, OKM, the parties and training units responsible for the competence requirements of training programmes. Healthcare and social care

1. Propose the preparation of a compulsory online course in infection control, tar- geted at healthcare professionals at regular intervals. Responsibility: STM, THL and hospital districts

2. Enhance and develop the share accounted by infection control, microbiology and clinical pathology of infectious diseases in the basic, further and continuing train- ing programmes of physicians, nurses and other healthcare professionals. Responsibility: STM, OKM, employers, institutes of higher education and organis- ers of professional training

3. Develop and utilise the materials in the Duodecim Oppiportti (“Learning portal”) and Terveyskirjasto (“Health Library”) in the training. In particular, produce web- based training materials. Responsibility: organisations and employers

4. Invest in the distribution of EAAD materials produced by ECDC, suitable for the situation in Finland. Responsibility: THL and hospital districts 20 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Animals and food safety

1. Enhance and develop the share of hygiene, microbiology and clinical pathology of infectious diseases in the basic and continuing training programmes of veteri- narians and animal keepers as well as animal attendants. Responsibility: MMM and OKM, institutes of higher education and organisers of professional training.

2. Increase training of veterinarians and other operators on the prudent use of anti- microbials and on their environmental impacts. Responsibility: industry sector organisations involved in food production ani- mals and fur animals, ETT, SEP, Suomen Kunnaneläinlääkäriliitto ry (Association of Finnish municipal veterinarians, Tuotantoeläinlääkäriyhdistys ry (Finnish Associa- tion for Food Animal Practitioners), Sikayrittäjät ry (Association of swine produc- ers), ELDTK, Evira. Veterinarians caring for animals in animal husbandry operator and owner trainings. 3. 3. Intensify provision of up-to-date information on antimicrobials to veterinarians. • Highlight better the issues, such as antimicrobial resistance and recommenda- tions of use of antimicrobials, on the websites of Evira and the Zoonosis Centre. • To support the work, a permanent veterinary working group representing various stakeholders and focusing on antimicrobials will be established. Responsibility: Evira 1.2 Education of the general public Current situation Eurobarometer surveys have repeatedly shown that the level of awareness about AMR is- sues is higher in Finland compared with the EU average (10). The AMR issue has been high- lighted many times in Finland by the European Antibiotic Awareness Day (EAAD) organ- ised by ECDC, and there have also been campaigns targeted at the Finnish general public. The ECDC website contains materials in the Finnish language. All actors of the sector have had very scarce resources for educating the general public and therefore no extensive visi- bility has been attained so far. Globally, there is AMR-related information material targeted at the general public as well as teaching materials for students of schools but very little of this material has been translated into Finnish. A good example is the British eBug project 21 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 (11). The health guide for tourists includes travelling-related health information, including knowledge about antimicrobial resistance. Objectives The objective is to increase the public awareness of antimicrobial resistance and the fac- tors impacting its increased prevalence as well as of the adverse effects of antimicrobials and the correct use of medicines in both human and animal healthcare. Attention is paid to those factors which individuals can affect, and thus contribute to reducing their risk of becoming exposed to resistant bacteria in their everyday life. Many studies show that tourists travelling to developing countries, where antimicrobials are used in abundance, clearly risk being colonised by resistant bacteria. Carried by the tourists, the resistant bac- teria spread all over the globe and also arrive in Finland. The educational material targeted at the public must pay attention to tourism as a factor that spreads resistance as well as to the actions that individual tourists can take to reduce the risk of colonisation. Vaccinations play a particular and significant role in combatting antimicrobial resistance. The public awareness of the importance of vaccinations for the prevention of infections as well as for the reduction of antimicrobial use, and thereby also for the control of antimicrobial resist- ance, must be increased. Actions

1. Considerably increase public education on the significance of tourism in the spreading of antimicrobial resistance. Responsibility: STM and THL

2. Propose more efficient utilisation of EAAD materials produced by ECDC for the education of the public. This applies particularly to the utilisation of materials re- lated to infections, vaccinations and use of antimicrobials. Responsibility: STM, institutes of higher education, Evira, THL, municipalities and hospital districts. 22 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021

3. Produce materials, for example, for health education teaching at school, e.g. by translating the British e-Bug project material into Finnish. Investigate the oppor- tunity for cooperation with Kustannus OY Duodecim Koulujen terveyskirjasto (School health library at Duodecim medical editors). Responsibility: STM, THL and institutes of higher education Animals and food safety

1. Intensify education on antimicrobial use targeted at owners of companion ani- mals and horses, including the environmental impacts of antimicrobials. Responsibility: Evira, ELTDK, SEP ry, veterinarians caring for animals in animal keeper and owner trainings.

2. Produce materials for consumers on the use of antimicrobials for the treatment of diseases in production and other animals as well as on the resistance risks associ- ated with stuffs. Responsibility: respective industry and Evira 23 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

2. Nationally coordinated One Health surveillance 2.1 Surveillance of antimicrobial resistance Current situation The surveillance of antimicrobial resistance produces comparable information on the trend in the resistance situation, also measuring the efficacy of the control measures. The surveillance also plays a role in the guidance related to antimicrobial use. Resistant bac- teria are spreading with unprecedented ease in the wake of increasing globalisation. The rapid identification of the bacteria that are extremely resistant to antimicrobials is vital for the launching of any control measures. In Finland, the identification of individual infec- tions and outbreaks caused by resistant microbes in humans is mainly the responsibility of clinical laboratories and infection teams but the outbreak investigations often also require typing data produced by reference laboratories. There is a need for this both in medicine and in veterinary medicine. The Finnish reference laboratory functions are concentrated at THL and Evira. No environmental antimicrobial resistance surveillance takes place in Fin- land. As a main rule, the national reporting on the antimicrobial resistance is in place and opera- tional. The Finnish resistance trend is well illustrated by the Finres, Tartuntataudit Suomes- sa (Infectious Diseases in Finland) and FINRES-Vet reports, with the latter being published every three years. Moreover, the resistance surveillance data on bacteria isolated from animals and foodstuffs is published in zoonosis reports. There is no nationwide joint report on AMR issues. Healthcare and social care The amended Communicable Diseases Act (12) obliges each director of a healthcare and social care unit to monitor the incidence of microbes that are very resistant to antimicro- bials. Moreover, the Act obliges laboratories engaged in microbiological diagnostics to 24 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 report the results of susceptibility testing to THL (12). The obligations under the Communi- cable Diseases Act cover both public and private operators. In Finland, the surveillance of antimicrobial resistance takes place both at the local and the national level. The national surveillance of resistance is based on several sub-areas. The Finres databaseis produced by FiRe which is a network of clinical microbiology laborato- ries that has been in operation since 1992. As early as 1997, it started to systematically and comprehensively collect susceptibility testing data on the major bacteria. As from 2008, the data has been stored in the Finres database maintained by TTR. The data collected on cases of multiresistant bacteria (CPE, ESBL, MRSA, VRE, MDR-TB), often completed with the typing data produced by the reference laboratory, is also entered in the TTR, which has been in operation since 1995. Both Finres and TTR are case-based, and their information is forwarded to the surveillance networks such as EARS-Net (13). The hospital infection programme SIRO has been collecting information on the healthcare-associated infections occurring in Finnish hospitals since 1999. The programme also collects data on the antimi- crobial susceptibility of the causative pathogens. Finland is a member of the ECDC surveillance network (EARS-Net), which has a long tradi- tion of focusing on the resistance of certain bacteria isolated from severe systemic infec- tions. The resistance surveillance by ECDC is based on the Decision No 1082/2013/EU of the European Parliament and of the Council with regard to the template for providing the information on preparedness and response planning in relation to serious cross-border threats to health (14). Finland is also participating in Global Antimicrobial Resistance Sur- veillance System (GLASS) under the auspices of WHO, launched in 2016 (15). As a collaboration of THLand clinical laboratories,national diagnostic guidelines focusing on multiresistant bacteria have been produced for clinical laboratories (16). The document is comprehensive and still updated but its implementation has not been followed-up. The guidelines related to the national laboratory diagnostics are important tools which can be used to ensure the use of correct and sufficiently coherent diagnostics in all parts of Fin- land. The Finres and TTR surveillance procedures are based on the information produced by clinical laboratories. Finnish laboratories comply with the pan-European EUCAST stand- ard for their susceptibility testing (19). More resources are required for the follow-up of any amendments of the EUCAST standard and its implementation. Animals and food safety The systematic resistance surveillance related to salmonellosis strains isolated from ani- mals and foodstuffs started in the 1980s in Finland. The comprehensive FINRES-Vet pro- gramme that focuses on the surveillance of the resistance of zoonosis and indicator bac- teria isolated from the most important production animal species started in 2002. More- 25 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 over, we follow the resistance situation of certain major animal pathogens and screen ESBL-producing bacteria from the most important production animals and their meat. The incidence of MRSA has been screened in swine and pork meat. The surveillance data is produced by Evira and by the University of Helsinki, Faculty of Veterinary Medicine as far as pets and horses are concerned. The legislation obliges approved laboratories to provide Evira with ESBL and MRSA bacterial strains for further testing. EFSA plays a central role in the design and steering of the resistance surveillance in the food chain as well as in the collection of EU-wide materials, analysis and publication of the respective results and risk assessments. The work by EFSA supports the preparatory work related to EU legislation. The European Commission’s 5-year Plan of Action against the threats of antimicrobial resistance also envisages the development of resistance surveil- lance programmes (18). According to the Directive 2003/99/EC (19), Finland sends resistance data related to the bacteria isolated from animals and foodstuffs to the EFSA zoonosis data collection sys- tem. In the EU, the harmonised part is based on the Commission’s transposition decision 2013/652/EU (20). Therefore, Finland not only has its national objectives but also interna- tional obligations to monitor antimicrobial resistance. In line with the Directive 2003/99/ EC (19), EFSA and ECDC compile an annual summary report on the outcomes of the EU- wide resistance surveillance related to humans and the food chain. Objectives The aim is to cater for local, national and international needs in the Finnish AMR surveil- lance. The ability to investigate microbial outbreaks must be retained. The requirements of the new Communicable Diseases Act regarding the surveillance of very resistant microbes must be taken into consideration. Moreover, we must also be able to react to unpredicted new future threats. The resistance surveillance focusing on bacteria isolated from animals and foodstuffs must remain at least at the current level while enhancing the surveillance related to pathogenic bacteria. The information on the resistance situation of microbes isolated from humans and animals and the respective trends must be easily accessible and comparable, especially as concerns zoonotic pathogens. The information on the national resistance situation will be communicated on an increasingly real-time basis to the public and the professionals. Actions Joint actions The up-to-date information on resistance must be made available of the social and health- care professionals as well as veterinary professionals and decision-makers by developing 26 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 the local, regional and national reporting systems. This will be possible with a common da- ta portal, for example. Moreover, attention must be paid to the usability of the information by linking the resistance data of TTR and Finres with the Duodecim Terveysportti health portal in an easily usable form. The possibilities to implement this must be discussed with Duodecim. Responsibility: STM, MMM Healthcare and social care

1. Develop a real-time notification and reporting system of extremely resistant an- timicrobial bacteria to support the exchange of information at the local, regional and national levels with the aim of enhancing appropriate control measures. Responsibility: THL

2. Develop the collection of susceptibility testing data (Finres/TTR) so that such data produced by clinical laboratories can be combined with the typing data pro- duced by the reference laboratories and the data collected in TTR. Responsibility: THL

3. Improve the collecting of resistance data on both the producer and collecting sides (for example, the XML definition from the Finres database) so that all labora- tories can easily transfer their data. Responsibility: THL

4. Enhance the capacity of clinical laboratories to adopt and maintain international standards (promotion of the EUCAST standard). Responsibility: THL

5. Influence the objectives related to AMR surveillance issued by ECDC and the respective implementation. It is of extreme importance and urgency that we promote the creation and introduction of common European standards for the surveillance of resistant bacteria, especially as concerns modern molecular micro- biological methods. Responsibility: STM 27 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

6. Propose, in view of more efficient surveillance and steering of antimicrobial use, that an expert group be established (if it does not already exist) in hospitals to follow and control AMR and steer the use of antimicrobials. The hospital manage- ment will set up the group that reports back to the management. The hospital will decide on the composition of the group but as the management’s commit- ment is important it should therefore be represented in the group. The group will analyse the antimicrobial consumption figures and indications of use at regular intervals, giving feedback to those who have prescribed the antimicrobials. Responsibilities: municipalities and hospital districts

7. Develop the surveillance of AMR related to viruses and fungi. Responsibility: THL, FiRe laboratories Animals and food safety

1. Increase the efficiency of FINRES-Vet surveillance and utilisation of materials. • Enhance the surveillance of resistance related to animal pathogens for all species • Produce targeted information on the resistance situation to veterinarians and ani- mal owners (animal pathogens, indicators, MRSA situation). • Produce information targeted at consumers on the resistance in foodstuffs of do- mestic and foreign origin • Increase a more analytic reporting of materials produced through the programme (publication of trend data) Responsibility: Evira

2. Promote the use of reliable and rapid laboratory diagnostics and susceptibility testing to support animal pharmacotherapies. • Provide guidance to commercial veterinary laboratories on the principles and quality requirements for antimicrobial susceptibility testing Responsibility: Evira • Remind veterinarians of the importance of sampling and the reliable testing of antimicrobial susceptibility of animal pathogens since the resistance data directs the use of medicines Responsibility: Evira and ELTDK 28 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021

3. Continue the surveillance of zoonotic, pathogen and indicator bacteria resistance following the EU legislation and national decisions. • The FINRES-Vet programme is updated annually, assessing its sufficiency, cover- age and materialisation taking international and national findings, research out- comes and risks into account Responsibility: Evira • Extend coverage of monitoring of foodstuffs of foreign origin Responsibility: Evira • For poultry, implement the ESBL/AmpC/carbapenemase producer monitoring based on the ETT importation instructions Responsibility: ETT, respective industry and Evira • Implement the resistance monitoring related to the E. coli strains (APEC) in poul- try Responsibility: Evira, the samples for testing delivered by the respective industry 2.2 Surveillance of antimicrobial use Current situation Healthcare and social care Finnish Medicines Agency Fimea produces statistics on the overall use of antimicrobials in Finland whereas the national insurance institution Kela has the opportunity to compile statistics on the reimbursable prescription-only medicines of humans. The antimicrobial committees and hygiene working groups instituted in certain hospitals have monitored the consumption of antimicrobials. Use information can also be retrieved from the hospi- tal pharmacy systems and patient information systems. All Finnish university and central hospitals have a commercial surveillance system of antibiotics and infections which makes it possible to monitor their antimicrobial use. The information of antimicrobials use in out- patient care can also be retrieved from the primary healthcare outpatient treatment infor- mation system Avohilmo. ESAC-Net is a European monitoring network (21) that has been collecting antimicrobial use data since 1997.THL has forwarded the materials received from Fimea to the network 29 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 since the beginning of its operation. The fact that the Fimea statistics cannot separate the information on antimicrobial use by acute hospitals and long-term care facilities has been a problem in these materials. Since 2011, Finland has conducted prevalence studies com- prising all EU Member States on healthcare-associated infections and antimicrobial use in hospitals (22). SIRO coordinates these studies made in Finland, cooperating with ECDC. Currently, there is no reliable understanding of how the Finnish hospital antimicrobial use has been developing in comparison with other European countries since the Fimea statistics do not allow for the separation of the antimicrobial use data in acute hospitals and long-term care facilities. Based on the prevalence studies, Finnish hospitals use more antimicrobials than the hospitals in other Nordic countries. Moreover, the production and utilisation of the antimicrobial use data retrievable from hospital pharmacy systems and patient data systems has not been systematic. In order to have comparable surveillance data, developing various statistics and information systems is of primary importance. Based on the ESAC-Net statistics (21), cephalosporins are in clearly more frequent use in Finnish outpatient care, compared with Sweden and Denmark, for example, and corre- spondingly the use of narrow-spectrum penicillins is far less frequent here than it is in the above countries. In fact, Finland ranks first in all Europe (all countries included in ES- AC-Net) in the use of first-generation cephalosporins. However, the hospital districts differ markedly regarding their overall consumption of outpatient antimicrobials (23). Animals and food safety Fimea monitors the quantity of antimicrobials used on animals on the basis of sales statis- tics provided by the pharmaceutical wholesalers. The consumption has been monitored since 1995 on the basis of weight unit reporting (kg of the active ingredient) by pharma- ceutical group. The current surveillance system does not cover the usage of human anti- microbials to companion animals. In proportion to the estimated number of companion animals, the sales numbers of tablet products approved for companion animals are higher in Finland than in the other Nordic countries. Finland has been involved in the project fo the European Surveillance of Veterinary An- timicrobial Consumption (ESVAC) since the beginning. The project takes the numbers of production animals into account. The sales of antimicrobials in proportion to the numbers of production animals have gone down in the 2010s while certain pharmaceutical groups show growth. The sales statistics do not provide information on the distribution of the use by animal species and therefore the reasons for the change are difficult to estimate. How- ever, it is known that the intensive mode of beef production, for example, has increased the need for antimicrobial treatments. 30 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Objectives The objective is to improve the surveillance and statistics of antimicrobial use in Finland, taking local, regional, national and international needs into account. In the monitoring of human medicines this means that the problems affecting Fimea’s statistics need to be rectified. Moreover, the information systems must be developed, particularly as concerns the local-level surveillance. The information on antimicrobial use must be easily accessible in an updated form from each hospital by speciality and from the outpatient care from the healthcare centre inpatient wards. This information must be placed in proportion with the scale of the operations and be given as feedback to the relevant operators. Information comprising the whole of Finland must also be produced in order to gain data for compari- sons. As concerns veterinary antimicrobials, we need a system to compile information on the use of the antimicrobials per animal species. Such information is needed in order to be able to recognise the heavy users of antimicrobials and to target instructions, advice and training measures at them. Actions Healthcare and social care General actions 1. 1. Fimea’s statistics and IT systems on antimicrobial use must be developed to al- low for an itemised analysis of antimicrobial consumption data of hospitals and long-term care facilities. Moreover, the reporting tools must be developed so that the compiled information can be utilised for local, national and international needs related to antimicrobial use. Responsibility: STM and Fimea Hospitals 1. 1. In view of more efficient surveillance and steering of antimicrobial use, it is pro- posed that an expert group be established (if it does not already exist) in hospi- tals to follow and control AMR and steer the use of antimicrobials. The hospital management will establish a group that reports back to the management. The hospital will decide on the composition of the group, but as the management’s commitment is important, it should also be represented in the group. The group will analyse the antimicrobial consumption figures and indications of use at regu- lar intervals giving feedback to those who have prescribed the pharmaceuticals. Responsibility: municipalities and hospital districts 31 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

2. The surveillance of local use is improved by developing information systems. Lo- cal surveillance is based, on the one hand, on the data of antimicrobial deliveries from hospital pharmacies and, on the other, on the information about antimi- crobial use and indications retrievable from patient information systems. Both surveillance systems must be developed and the existing systems put to more efficient use. Responsibility: municipalities, hospital districts, THL and Fimea

3. Ensure Finland’s participation in the prevalence studies conducted in EU Member States. Responsibility: STM, THL and hospital districts Outpatient care

1. Fimea will investigate the possibilities of use of the electronic prescription da- tabase as a tool for more detailed antimicrobial consumption follow-up, also re- garding the prescriptions that do not entitle the patient to reimbursements. The objective is to use the data of the dispensed electronic prescriptions as a tool for more detailed surveillance of the consumption of antimicrobial. This will allow ac- cess to user numbers categorised by gender and age groups. Responsibility: Fimea

2. Investigate the possibilities of utilising the data on Avohilmo system. Responsibility: STM and THL

3. Investigate how the Kela statistics on reimbursable prescription-only medicines could be used in the surveillance of antimicrobial use in outpatient care. Responsibility: STM and Kela Animals and food safety

1. Construct an information system to collect user data on antimicrobials covering all animal species. • The information system will allow the veterinarians and farms to benchmark their own level of usage, based on the collected use data. The information will also be 32 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 used for surveillance and for identifying the objects of possible surveys of antimi- crobial resistance. • The IT system would also allow the surveillance of separately chosen antimicrobi- al groups: − For all animal species, use of antimicrobials that are critically im- portant (fluoroquinolones, macrolides and third and fourth gen- eration cephalosporins) − Use of antimicrobials on companion animals Responsibility: MMM, Evira

2. Provide the authorities with access to the national compilation data (quantities, active ingredients, indication) on poultry antimicrobial medication through ETT. Develop the capability to provide the corresponding national compilation data on swine (Sikava) and on cattle (Naseva). Responsibility: ETT and the respective industry sectors 33 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

3. Preventing infections and controlling the spread of multidrug-resistant bacteria 3.1. Preventing infections Current situation In the WHO’s Action Plan on Antimicrobial Resistance, the prevention of infections plays a major role for the combat against antimicrobial resistance (4). Improved hygiene and vaccinations are the most important measures on the global scale. In Finland, the preven- tion of infections can be a tool to decrease the use of antimicrobials. For example, the use of pneumococcus vaccines has diminished the incidence of serious infections caused by pneumococcus but also reduced antimicrobial resistance and the use of antimicrobials in certain age groups. Correspondingly, the influenza vaccine can be used to prevent not only the actual influenza infection but also bacterial secondary diseases, such as infections of the respiratory tract caused by pneumococcus. Among the tourist vaccines, the typhoid vaccine protects against the resistant Salmonella typhi bacteria that have become more common over the past few years. Besides outpatient care, the prevention of infections also applies to healthcare facilities. Hospitals have local and regional instructions of infection prevention. Various measures and practices of infection prevention have been compiled in a Finnish-language book that will be updated during 2017 and published online. For several decades, Finland has aimed in reducing the need for antimicrobial medication in animals by eradicating animal diseases as well as by carrying out efficient herd health work by the industries themselves. Good animal production and living conditions togeth- er with herd health measures constitute the primary ways to prevent infectious diseases. However, this is not enough. The breeding animals as well as companion animals import- ed from abroad introduce resistant microbes in Finland, including ESBL strains. Compan- ion animals also carry multidrug-resistant bacteria. They can also be transferred to the hu- mans in contact with the animals. In turn, human pathogens can transfer to animals and from them back to humans (e.g., MRSA). 34 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Objectives The objective is the prevention of infections to reduce the overall need to use antimicrobi- als. Another objective is to keep the risks caused by the travelling of humans and animals as well as by the importation of animals and foodstuffs to the disease and resistance situa- tion at a reasonable level. Moreover, efficient herd health measures will prevent the spread of pathogens and resistant microbes in the Finnish animal population, improve animal health and diminish the need for medication. Actions Healthcare and social care

1. Prepare national recommendations for infection prevention at hospitals and long-term care facilities. Responsibility: STM, municipalities, THL and hospital districts

2. Create a web portal for all healthcare professionals, which contains links to the infection prevention instructions of various hospital districts and to the textbook called Hoitoon liittyvien infection torjunta (Combat of healthcare-associated in- fections). Responsibility: THL and hospital districts

3. Develop the surveillance system of the burden of infectious diseases. Responsibility: THL and hospital districts Animals and food safety

1. The food industry implements - as instructed by ETT and exceeding the statuto- ry requirements - quarantine and examination practices for the importation of all production animal materials to prevent the entry into Finland of predisposing viral infections and difficult-to-manage bacterial infections. Responsibility: relevant industries, animal importers and ETT

2. The production structure of production animals will be retained so that the ani- mal wellfare and health can be maintained, reducing the use of antimicrobials. Responsibility: the industry in question, producers and ETT 35 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

3. Prepare a biosecurity plan for all production animal farms to prevent the spread of infectious diseases. • Biocheck will be introduced for the evaluation of both the farm’s internal and ex- ternal biosecurity. The farm will identify the items, which it must focus on in its operations. Responsibility: the industry, ETT, production chain and veterinarians responsible for the herd health of the farms

4. Intensify measures to ensure the availability of medicines in the Finnish market. • Ensuring the availability of vaccines necessary for the prevention of diseases • Ensuring the availability of narrow-spectrum antimicrobials such as penicillin, in particular, as well as other old antimicrobials. • The production animal industry, veterinarians and Evira’s expert groups for differ- ent animal species will highlight the problems Responsibility: MMM, STM, Evira, Fimea and pharmaceutical branch operators

5. In target programmes focusing on canine breeding, a clearly negative stand will be taken on the use of atopic and allergic dogs in breeding. Likewise, anatomic features making dogs susceptible for infectious diseases, such as excessive fold- ing of the skin, will be eradicated in breeding, also through the training and in- struction of judges in dog shows. Responsibility: The Finnish Kennel Club and breed associations

6. In fur animal production, the health and wellfare of animals will be maintained in order to be able to reduce the use of antimicrobials. Responsibility: Fur industry 3.2. Combat of multidrug-resistant bacteria Current situation Healthcare and social care Multidrug-resistant bacteria (CPE, ESBL, MRSA, VRE, MDR-TB, MDR-Pseud, MDR-Aci) con- stitute a severe problem globally. Research has shown that in developing countries, the colonisation of populations by multidrug-resistant bacteria, such as the ESBLproducing E. coli strains are very common. Every year, about 350,000 people travel from Finland to such 36 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 countries, and about one third of these tourists becomes colonised by multidrug-resist- ant bacteria during their trip (24). We have very limited possibilities to impact the global spreading of multidrug-resistant microbes. Therefore, the focus of prevention must be on the control of the resistance carried to the country and in the prevention of local spread- ing. It is mostly a question of patients with no symptoms carrying the bacteria, and more rarely of infections with clinical symptoms. The combat of multidrug-resistant bacteria in healthcare facilities includes screening for the bacteria and prevention of their spreading. There are national guidelines of prevention (25), which are used by the hospital district to produce their regional instructions. Like- wise, there are national guidelines of laboratory diagnostics (16), based on the recommen- dation of the EUCAST expert working group. THL, especially its reference laboratory, plays a central proactive, instructive and converging role in the combat against the spreading of multidrug-resistant bacteria. The registers maintained by THL, on the one hand, and the classification of bacterial strains by the THL laboratories, on the other, play a key role in the surveillance of multidrug-resistant bacteria. Typing data is also needed to support the in- vestigation of local outbreaks. Multidrug-resistant bacteria are carried to Finland by tourists and patients discharged from foreign healthcare facilities. For example, according to THL statistics in 70% of the CPE findings, the patient had a preceding foreign contact. The educational material target- ed at the public must deal with tourism as a factor that spreads resistance as well as to the actions that individual tourists can take to reduce the risk of colonisation. Animals and food safety Finland has issued national objectives related to the salmonellosis in poultry, swine and cattle. However, there are no corresponding objectives issued in relation to the incidence of multidrug-resistant bacteria. For example, the grandparent and preceding generations of poultry carry ESBL bacteria to Finland. Likewise, there are MRSA bacteria in swine. The means to prevent the spreading of multidrug-resistant bacteria in animals are largely the same as for infection prevention. The relevant industry is introducing the assessments of disease protection for swine farms. The hygiene measures of veterinary clinics and hos- pitals, can prevent the spread of resistant bacteria. However, there are no national guide- lines for this. Objectives The objective is to prevent the outbreaks caused by the multidrug-resistant bacteria (the most important among them being CPE and MRSA) in healthcare facilities. Another ob- 37 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 jective is to try to identify means to combat resistance carried across borders. National objectives will be set regarding the incidence of the major multidrug-resistant bacteria in animals, and the control measures will be agreed upon. Actions Healthcare and social care

1. Develop a real-time notification and reporting system focusing on extremely an- timicrobial- resistant bacteria to support the exchange of information at the local, regional and national levels and to ensure appropriate control measures. Responsibility: STM and THL

2. Ensure the operating conditions of THL in the AMR surveillance and outbreak in- vestigations by allocating sufficient funding. Responsibilities: STM and THL

3. Ensure that the national and local recommendations for control multidrug-resist- ant bacteria are current and updated and that healthcare staff receive training. Responsibility: STM, municipalities, hospital districts and THL

4. Increase tourist information regarding the role of tourism in the spreading of mul- tidrug-resistant microbes. In addition to informing, the education must focus on the ways the tourists can decrease the risk of colonisation during their travels. Responsibility: STM and THL 38 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Animals and food safety

1. Produce guidelines on the prevention of infections caused by work-related re- sistant bacteria of animal original and draft joint operational principles for health and environmental health professionals to investigate and control the occurrence of human diseases caused by resistant bacteria of animal origin. Responsibility: TTL, THL and Evira • Set national objectives for the control measures focusing on major pathogens: • Set the appropriate level of protection (ALOP) for the incidence of zoonotic path- ogens (such as LA-MRSA, ESBL) and resistant microbes in production animals and foodstuffs • Agree on national control measures Responsibility: MMM. STM, THL and Evira

2. Enhance the competence in infection control at animal health clinics and hospi- tals, and provide them with information on good practices. Responsibility: Evira, ELTDK and veterinarians in charge of the disease controls at the clinics and animal hospitals 39 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

4. Guidelines on antimicrobial use for professionals Current situation Healthcare and social care The use of antimicrobials is a major resistance-increasing factor. The actions proposed by international communities recommend curbing the excessive use of antibiotics. In the western world, the three most common reasons for unnecessary antibiotics use include vi- ral infections of the upper respiratory tract, symptomless bacterial growth in urine (bacte- riuria) and tourist diarrhoea. According to the information gathered by the ESAC-Net network, the Finnish use of an- timicrobials exceeds the Swedish, Norwegian and Danish levels (20), although the differ- ence compared with Norway and Denmark is small. Most of the antimicrobials are used in outpatient care, accounting for about 87% of the whole consumption in 2015. Through- out the 2000s, the overall use of antimicrobials has decreased in Finland. However, there are major qualitative differences in the use of antimicrobials. In Finnish outpatient care, the use of cephalosporins is clearly more frequent than, e.g., in Sweden or Denmark, while narrow-spectrum penicillins are used more rarely. In fact, Finland ranks first in all of Europe (all countries included in ESAC-Net) in the use of first-generation cephalosporins. The use of antimicrobials has been the object of national steering since the 1990s, with the Current Care Guidelines coordinated by the medical society Duodecim since 1999. The Current Care Guidelines have become an important healthcare tool (Table 2).There are national-level guidelines for acute and intensive care therapies, which also include instruc- tions on antimicrobial use. In addition to these recommendations, almost all hospitals have their own antimicrobial guidelines and instructions. However, there is no general-lev- el national recommendation on the use of antimicrobials in outpatient care. The European Council issued its recommendation on antimicrobial use as early as 2001 (26). Moreover, the Commission collaborated with ECDC to publish new general guidelines on the use of antimicrobials (27). Finland does not have a corresponding national recommendation on the use of antimicrobial therapies. 40 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Table 2. Current care guidelines Published/latest update Diabetes-related foot problems 29 June 2009 Antimicrobials in acute dentistry 27 May 2011 Bacterial skin infections 8 November 2010 Pharyngitis 12 March 2013 Sepsis 2 January 2014 Fungal infections of the skin, hair and nails 12 March 2010 Sinusitis 10 June 2013 STD 30 June 2010 Acute otitis media 11 January 2010 Lower respiratory tract infections in adults 2 January 2015 Lower respiratory tract infections in children 26 June 2015 Urinary tract infections 4 December 2015 Animals and food safety The control of antimicrobial use in animals through legislation and recommendations has existed for long time in Finland. As early as in 1996, the Ministry of Agriculture and Forest- ry issued the first examples of antimicrobial use for the major infectious and contagious diseases affecting animals in Finland. Since then, they have been updated three times in the form of recommendations of use. The changes in animal morbidity, treatment concep- tions and pharmaceutical selections have been taken into account in the updated rec- ommendations (28). The industry itself has detailed instructions for the prevention and treatment of the major diseases but more are needed. All in all, the measures promoting prudent use of antimicrobials have focused on production animals. Objectives The objective is the prudent use of antimicrobials, in other words, to use antimicrobials for the treatment of infections on medical grounds in humans and veterinary medicinal grounds in animals. If necessary, samples are taken to analyse the antimicrobial suscepti- bility of the pathogen using reliable methods. The medication chosen is an optimally effi- cient option that targets the cause of the infection with optimal precision. Antimicrobials are disposed of in an appropriate manner. Infections are treated with therapies and med- icines other than antimicrobials whenever possible. Moreover, measures are taken to pre- vent infections. Humans and animal owners are educated in antimicrobial use and AMR. The objective is to reduce AMR and the adverse impacts caused by the antimicrobials to human and animal patients, the population at large and the environment. 41 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Healthcare and social care The objective is to reduce the overall consumption of antimicrobials in hospitals, long- term care facilities and in outpatient care to the common Nordic level. At the same time, the objective is to replace the broad-spectrum antimicrobials, as applicable, by nar- row-spectrum antimicrobials. Animals and food safety The objective is that the overall use of animal antimicrobials will not increase and the use of critically important antimicrobials will decrease, in production animals the antimicrobi- al use will not increase and the use of narrow-spectrum antimicrobials will remain at the current level. Moreover, the objective is to reduce the use of antimicrobials in companion animals. Actions Healthcare and social care

1. Prepare a national antimicrobial manual for outpatient healthcare to cover the antibiotics choices, dosage and duration of the treatment of usual infections treated in outpatient care. Responsibility: STM

2. Continue the updating of existing Current care guidelines, taking the medica- tion use objectives stated above into account (choice of antibiotics and duration of therapies). New recommendations are also needed, such as the Vältä viisaasti (Avoid rationally) recommendations and the national antimicrobial prophylaxis instructions for surgical fields. Responsibility: STM

3. In view of more efficient surveillance and steering of antimicrobial use, it is pro- posed that an expert group be established (if it does not already exist) in hospi- tals to follow and control AMR and steer the use of antimicrobials. The hospital management will set up the group that reports back to the management. The hospital will decide on the composition of the group, but as the management’s commitment to the issue is important, it should also be represented in the group. The group will analyse the antimicrobial consumption figures and indications of use at regular intervals giving feedback to those who have prescribed the phar- maceuticals. Responsibilities: municipalities and hospital districts 42 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021

4. Propose that all hospitals should have their own recommendations for the use of antimicrobials in infections. Responsibility: municipalities and hospital districts Animals and food safety

1. Set national objectives for the volume of antimicrobial use in animals • For all animal species, use of antimicrobials that are critically important (fluoro- quinolones, macrolides and third and fourth generation cephalosporins) • Decrease in use of antimicrobials on companion animals, with a volume objective set for the decrease Responsibility: MMM, Evira

2. The respective industry will consider the setting of its own objectives in order to limit the use of critically important antimicrobials in production animals. Responsibility: industry and ETT

3. Recognise animal groups with a higher use of antimicrobials compared with oth- er groups, and take measures to reduce the need to use them. Responsibility: industry, ETT, veterinarians and animal health authorities

4. Update the recommendations of use of animal antimicrobials at regular intervals, and publish the recommendations in the form of a mobile application. Responsibility: Operative responsibility Evira, expertise ELTDK, ETT, SEP, TEY and other experts in veterinary medicine

5. Instructions with significant impact on the decrease in the use of antimicrobials and zinc oxide. • Update the piglet weaning guidelines, with respective training Responsibility: MMM, ETT, industry, feed industry, advisory parties, slaughter- houses, structural planning experts, Evira and other expert parties • Poultry medication guidelines and operating instructions for poultry farms in view of botulism Responsibility: ETU poultry groups 43 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

6. Highlight the aspects of prudent use of antimicrobials actively in marketing au- thorisation procedures. Responsibility: Fimea 44 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021

5. Research Current situation During the years 2011–2016, the government funding allocated to the research in health- care has decreased more than in any other discipline. According to TEM, the healthcare re- search funding in 2016 was only 37% of what it used to be in 2011. A small speciality such as the research in AMR has not been able to obtain the necessary funding from the nation- al research financing parties. Through the Academy of Finland, Finland has been a mem- ber of the EU-wide Joint Programming Initiative on Antimicrobial Resistance, JPIAMR since the launching of its planning stage in 2008. To date, the Academy of Finland and Tekes have not participated, as far as financing is concerned, in the JPIAMR funding application rounds and therefore the Finnish researchers have not qualified as applicants. There have not been any rounds of national funding applications focusing specifically on AMR. During the past decades, the Finnish AMR research has been well represented in the international fora. Since Finland cannot combat AMR on its own, the importance of international con- tacts should be particularly emphasised in the future. The research on AMR has been carried out not only by the universities and university hos- pitals but also by THL and Evira. The government austerity measures have clearly reduced the proportion of research in THL’s operations, with the activities concentrated merely on the tasks imposed by the Infectious Disease Act, such as the AMR surveillance and out- break investigations. The focus of research operations has shifted increasingly to the uni- versities and university hospitals. However, THL still compiles and maintains a sizeable col- lection of microbial strains and extensive population-level materials that can be used for research purposes. Individual research projects have focused on the environmental issues related to AMR. The diagnostics industry has a long tradition in Finland. This also applies to microbiologi- cal diagnostics. Moreover, there are new Finland-based business operations focusing on diagnostics. There have also been several joint research projects in Finland carried out in partnership by universities and businesses and some of them have at least partially been related to AMR and microbiological diagnostics. Diagnostic development requires persis- tent collaboration by several sectors, including combinations such as research institutes, 45 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 industry and clinics, and laboratories and clinics. As enablers of this collaboration, the measures taken by public funding sources play a central role: Finland would have good potential to create a well-functioning innovation ecosystem in the diagnostic sector by supporting the existing programmes and making new strategic openings. WHO has de- clared that the combat against AMR is a global priority. It is probable that these significant and comprehensive objectives will generate future opportunities to develop commercial products, especially in the field of microbial diagnostics. In particular, rapid and reliable point-of-care diagnostics will be in demand in connection with the objective of reducing the use of antimicrobials. JPIAMR performed a survey on the public research funding allocated to AMR in 2007–2013 in 19 different countries. In Finland, the survey only focused on the research funding by the Academy of Finland and the EU. According to plan, the survey will be repeated in 2017. Objectives The research on AMR and infectious diseases is the most efficient way to ensure the Finn- ish expertise in the field. It is vital to conduct basic research in AMR to understand the var- ious factors of resistance origination and mechanisms. There will be no applied science un- less there is preceding basic research. State-of-the art research also provides international visibility which is vital for making international contacts. The primary objective is to get the significant Finnish research funding parties, such as the Academy of Finland and Tekes, to allocate resources to the research in AMR and infectious diseases in Finland, thereby promoting the wellbeing of Finnish people. In addition to ensuring the research funding to sectorial research institutes or universities, the development of the Finnish diagnostic industry must also be supported to enable it to respond to the current and future needs. The networking of various actors must be enhanced significantly. To be able to assess the need for any further measures, it is necessary to have basic information on the presence and impacts of antimicrobials in the environment as well as on the incidence and spread of AMR through the environment. Actions

1. Map the activities of the research groups operating in this sector in Finland, sup- porting the networking of the research and other actors both in Finland and in- ternationally. Responsibility: OKM, universities and research institutes 46 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021

2. Propose a basic research programme to be instituted by the Academy of Finland, with special focus on AMR and other infectious disease research as well as on re- lated environmental issues. Responsibility: universities and research institutes

3. Propose applied R&D projects to Tekes, focusing on AMR diagnostics and, more extensively, on infectious disease diagnostics. Responsibility: universities, research institutes and the diagnostics industry

4. Propose the combat of AMR as one of the strategic areas of the research funding allocated by the VNK. Responsibility: STM

5. Ensure the continued future funding of local research operations (university hos- pitals, central hospitals). Responsibility: municipalities, hospital districts, STM and OKM

6. Promote and support the research on AMR and infectious diseases in the veteri- nary science, focusing on the MAKERA priorities: disease combat, disease protec- tion and production methods; development of rapid and reliable diagnostic tests; measures to promote prudent use of antimicrobials; combatting resistance and its incidence in animals and foodstuffs; as well as the research in resistance mech- anisms. Responsibility: MMM, universities and research institutes 47 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

6. Administrative structures Current situation The central ministries for the combat of AMR are the Ministry of Social Affairs and Health STM, the Ministry of Agriculture and Forestry MMM, the Ministry of the Environment YM and the Ministry of Education and Culture OKM. The Ministries and the agencies and re- search institutes under their umbrella, the institutes of higher education and organisers of vocational education as well as labour market organisations and other actors all collabo- rate to ensure that the One Health approach is followed in the combat of AMR. The respec- tive legislation is listed in Appendix 2. The STM is responsible for the legislation on the prevention of infectious diseases, gener- al planning, steering and surveillance, including the combat against AMR. The objective is to prevent infectious diseases and their proliferation. The preventive work takes place pri- marily within the social care and healthcare system, with the expert support provided by THL. Enacted in March 2017, the new Communicable Diseases Act attributed the respon- sibility for combat of AMR not only to the healthcare operative units but also to the social care units which collaborate with the regional infection experts. STM is also responsible for the legislation on the protection of health and chemical surveillance as well as on the steering of the prevention of environmental health hazards. The Finnish Medicines Agen- cy Fimea is responsible for the marketing authorisations of pharmaceuticals as well as the supervision of pharmaceutical wholesalers and pharmacies. MMM is responsible for the legislation on animal diseases, animal welfare and medication as well as food safety, and for general planning and steering. The combat against AMR is a part of the above sectors. The central actors include veterinarians, animal owners, compa- nies, interest organisations and training units. The Faculty of Veterinary Science of the Uni- versity of Helsinki is responsible for the professional basic education of veterinarians. As the superior authority in the sector, MMM steers and supervises the use of medicines and medicated feeds administered to animals. The Finnish Food Safety Authority Evira is the central government authority to steer and supervise the implementation of and compli- ance with legislation on animal medication. Regional State Administrative Authorities take 48 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 care of the supervision and instructions related to animal medication in their respective areas of competence. In accordance with its competence area, YM adds the environmental protection perspec- tive to the combat against AMR. The environmental administration does not have any leg- islation-based role in this issue. The environmental permits of farms or wastewater treat- ment plants covered by the Environmental Protection Act do not regulate the releases of antimicrobials or resistant microbes into the environment, and are thus neither supervised by the Centres for Economic Development, Transport and the Environment (ELY centres). The Finnish Environment Institute performs research on the environmental impacts of pharmaceutical substances. OKM is responsible for the education and science policy. This administrative sector is re- sponsible for the planning and implementation of the policies of higher education and science, also preparing the respective legislation. OKM also steers the system of institutes of higher education and research, supporting the operative conditions of research organi- sations. OKM prepares the vocational training legislation and steers and supervises the re- spective field. OKM issues the authorisations to organise training and the contents related to the authorisation. Objectives • Ensure the inclusion of combat of AMR in the legislation of the appropriate ad- ministrative sectors. • Maintain and enhance the conditions for reaching the national and international objectives in the combat of AMR in collaboration between the various administra- tive sectors and stakeholders. For example, WHO, EU, OIE, FAO and Codex Alimen- tarius have issued several objectives which Finland is also committed to (Appen- dix 1). • Adopt an order of priority and urgency for the measures. • Ensure the appropriate sufficiency of resources. • Ensure the inclusion of the regulations related to the combat of AMR in all legis- lation to be modified in the context of the reform of the regional and social care and healthcare systems. • Steer and support the implementation of the new obligations under the Infec- tious Disease Act in order to prevent treatment-related infections and AMR. • Enhance the legislative development on antimicrobials, veterinary medicines and medicated feeds at the EU and national level. • Develop and strengthen the collaboration and commitment to the combat against AMR in the appropriate industries and branches. • Support and promote introduction of international standards in Finland. 49 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 Actions

1. Ensure the inclusion of the combat of AMR in the legislation of the appropriate administrative sectors. Each Ministry will be responsible for the implementation of the specific actions related to their own administrative sector.

2. Enhance administrative cooperation across and between branches and stake- holders by consolidating the operations of the national expert group (MTKA) through, for example, a legislative decree.

3. Agree on the order of priority and urgency of the actions as well as on the time- frame of the measures, organising the necessary resources in terms of time and personnel.

4. Monitor the implementation and outcomes of the national action plan on AMR through annual reports and develop the action plan if necessary.

5. Impact the legislation at the EU level.

6. Continue to engage in international cooperation and commitment to the preven- tion of AMR on all sectors. Responsibility: STM, MMM, OKM, YM 50 NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Follow-up of the implementation of the Action Plan The implementation of the Action Plan calls for an active contribution by several actors. The central actors include, among the Ministries, STM, MMM, YM, OKM, TEM and the agen- cy under their auspices (THL, Evira, the university, the Academy of Finland, TEKES, OPH), hospital districts, other municipal and private healthcare and animal herd health oper- ators, the actors in the laboratory sector and food safety as well as the diagnostics and pharmaceutical industries. Some of the measures will also require separate funding. Insti- tuted by THL, MTKA will follow the implementation of the programme at the national lev- el. It has the annual task of assessing the implementation of the programme and reporting on the situation to the Ministry of Social Affairs and Health and Ministry of Agriculture and Forestry 51 PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 References

1. The review on antimicrobial resistance, Chaired by Jim O’Neill: https://amr-review.org/sites/default/ files/160525_Final%20paper_with%20cover.pdf

2. World Economic Forum: Global Risks 2014, Ninth ed., Geneva 2014 (www.weforum.org/risks)

3. WHA67.25: http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R25-en.pdf?ua=1&ua=1

4. Global action plan on antimicrobial resistance, WHO: http://apps.who.int/iris/bitstre am/10665/193736/1/9789241509763_eng.pdf?ua=1

5. A manual for developing national action plans, WHO: http://www.who.int/drugresistance/action-plans/ manual/en/

6. Global Health Security Agenda: http://stm.fi/ministerio/kansainvaliset-asiat/ghsa

7. The OIE Strategy on Antimicrobial Resistance and the Prudent Use of Antimicrobials: http://www.oie.int/ fileadmin/Home/eng/Media_Center/docs/pdf/PortailAMR/EN_OIE-AMRstrategy.pdf

8. Action plan against the rising threats from Antimicrobial Resistance, European Comission: http://ec.europa. eu/dgs/health_food-safety/docs/communication_amr_2011_748_en.pdf

9. Bakteerien lääkeresistenssin torjuminen ja mikrobilääkepolitiikan kehittäminen, STM työryhmämuistio 2000:4 http://julkaisut.valtioneuvosto.fi/handle/10024/73988

10. Eurobarometer: http://ec.europa.eu/dgs/health_food-safety/amr/docs/eb445_amr_generalreport_en.pdf 11. e-Bug: http://www.e-bug.eu/fl_home.aspx?ss=1&cc=fl&t=Tervetuloa%20opettajien%20e-Bug-sivustolle

12. Tartuntatautilaki 1227/2016 http://www.finlex.fi/fi/laki/alkup/2016/20161227

13. EARS-Net: http://ecdc.europa.eu/en/healthtopics/antimicrobial-resistance-and-consumption/antimicrobi- al_resistance/EARS-Net/Pages/EARS-Net.aspx

14. Euroopan parlamentin ja neuvoston päätös 1082/2013/EU valtioiden rajat ylittävistä vakavista terv- eysuhkista: http://ec.europa.eu/health/preparedness_response/docs/decision_serious_crossborder_ threats_22102013_fi.pdf

15. Global Antimicrobial Resistance Surveillance System (GLASS), WHO: http://www.who.int/drugresistance/ surveillance/glass-enrolment/en/

16. Ohje moniresistenttien bakteerien diagnostiikasta – Toteaminen, resistenssimekanismit ja kantajuusseu- lonnat: http://urn.fi/URN:ISBN:978-952-302-615-5

17. EUCAST: http://www.eucast.org/

18. Action at EU Level: http://ec.europa.eu/dgs/health_food-safety/amr/action_eu/index_en.htm

19. Euroopan parlamentin ja neuvoston direktiivi 2003/99/EY: http://eur-lex.europa.eu/legal-content/FI/TXT/ HTML/?uri=CELEX:32003L0099&from=EN

20. Comission Implementing Decision 2013/652/EU: http://eur-lex.europa.eu/LexUriServ/LexUriServ. do?uri=OJ:L:2013:303:0026:0039:EN:PDF

21. ESAC: http://ecdc.europa.eu/en/healthtopics/antimicrobial-resistance-and-consumption/antimicrobi- al-consumption/ESAC-Net/Pages/ESAC-Net.aspx

22. Prevalenssitutkimus: https://www.thl.fi/fi/web/infektiotaudit/seuranta-ja-epidemiat/hoitoon_liittyvien_ infektioiden_seuranta/prevalenssitutkimus

23. Maunuksela, Huovinen, Vuopio: Suomessa käytetään Pohjoismaista eniten mikrobilääkkeitä avohoidossa; SLL 2015; 70, 36: 2259-2263.

24. Kantele A, Lääveri T, Mero S, Vilkman K, Pakkanen SH, Ollgren J, Antikainen J, Kirveskari J. Antimicrobials increase travelers’ risk of colonization by extended-spectrum betalactamase-producing Enterobacteriace- ae. Clin Infect Dis. 2015 Mar 15;60(6):837-46.

25. Ohje moniresistenttien mikrobien tartunnantorjunnasta: http://urn.fi/URN:ISBN:978-952-302-260-7

26. Council recommendation: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=O- J:L:2002:034:0013:0016:EN:PDF

27. Proposals for draft EU guidelines on the prudent use of antimicrobials in human medicine – See more at: http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=- 4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1539

28. Mikrobilääkkeiden käyttösuositukset eläinten tärkeimpiin tulehdus- ja tartuntatauteihin https://www.evi- ra.fi/globalassets/tietoa-evirasta/julkaisut/julkaisusarjat/elaimet/mikrobilaakkeiden_kayttosuositukset_fi- 004.pdf

29. Ruth Kelly, Ghada Zoubiane, Desmond Walsh, Rebecca Ward, Herman Goossens: Public funding for re- search on antibacterial resistance in the JPIAMR countries, the European Commission, and related Europe- an Union agencies: a systematic observational analysis. Lancet Infect Dis 2016;16: 431–40. 52 Action Plan on Strategic objectives and areas of operation grouped on the basis of the WHO Action Plan Antimicrobial Resistance Training and Monitoring and Preventing resistance Steering of use of Research Administration Other education surveillance and infections antimicrobials WHO Objective 1: Objective 2: Objective 3: Objective 4: Objective 5: Global Action Plan on Improve awareness Strengthen the Reduce the inci- Optimize the use of Develop the eco- Antimicrobial Resistance 2015 and understanding knowledge and evi- dence of infection antimicrobial medi- nomic case for sus- of antimicrobial dence base through through effective cines in human and tainable investment

Appendix 1 http://www.wpro.who.int/enti- resistance through surveillance and re- sanitation, hygie- animal health that takes account ty/drug_resistance/resources/ effective search ne and of the needs of all global_action_plan_eng.pdf communication, infection prevention countries, and in- education and trai- measures crease investment ning in new medicines, diagnostic tools, vaccines and other interventions Finland Area of operation 1: Area of operation 2: Area of operation 3: Area of operation 4: Area of operation 5: Area of operation 6: 53 National Action Plan on Training of profes- Nationally coordi- Preventing in- Guidelines on an- Research Administrative Antimicrobial Resistance 2017- sionals and edu- nated One Health fections and timicrobial use structures 2021 cation of general surveillance controlling the for professionals public Monitoring of AMR spread of multi- and use of antimi- drug-resistant crobials bacteria NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 Action Plan on Strategic objectives and areas of operation grouped on the basis of the WHO Action Plan Antimicrobial Resistance Training and Monitoring and Preventing resistance Steering of use of Research Administration Other education surveillance and infections antimicrobials European Commission Area 7: Area 5: Area 2: Area 1: Area 6: Area 4: Area 3: Communication from the Improving commu- Improving monitor- Preventing micro- Making sure anti- Promoting research Joining forces with Developing new ef- Commission to nication, education ing and surveillance bial infections and microbials are used and innovation international part- fective antimicro- the European Parliament and and training in human and ani- their spread appropriately in ners to contain the bials or alternatives the Council mal medicine both humans and Action n° 11: risks of spreading for treatment Action plan against the rising Action n° 12: Survey Action n° 4: animals Reinforce and co-or- AMR from inter- threats from Antimicrobial and comparative ef- Action n° 9: Strengthen infec- dinate research national trade and Action n° 6: To pro- Resistance 2011-2016 fectiveness research Strengthen surveil- tion prevention and Action n° 1: efforts travel and via the mote, in a staged lance systems on control in healthcare Strengthen the environment approach, unprece- Contains 12 actions for imple- AMR and antimi- settings promotion of the dented collaborative mentation with EU Member crobial appropriate use of Action n° 8: Develop research and devel- States and identifies 7 areas consumption in hu- Action n° 5: antimicrobials in all and/or strengthen opment efforts to where measures are most man medicine Introduction of the Member States multilateral and bring new antibiot- 54 needed new Animal Health bilateral commit- ics to patients Action n° 10: Law, which will fo- Action n° 2: ments for the pre- http://ec.europa.eu/dgs/ Strengthen surveil- cus on Strengthen the regu- vention and control Action n° 7: Promote health_food-safety/docs/com- lance systems on prevention of diseas- latory framework on of AMR in all se- efforts to analyse munication_amr_2011_748_ AMR and antimi- es, reducing the use veterinary medicines ctors. the need for new en.pdf crobial of antibiotics and re- and on antibiotics into consumption in ani- placing current medicated feed veterinary medicine mal medicine Animal Health pro- visions based on dis- Action n° 3: ease control Introduce recom- PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12 mendations for pru- dent use in veteri- nary medicine, including follow-up reports, using the same approach as 2002 Council Recommendation on prudent use of anti- microbial agents in human medicine Action Plan on Strategic objectives and areas of operation grouped on the basis of the WHO Action Plan Antimicrobial Resistance Training and Monitoring and Preventing resistance Steering of use of Research Administration Other education surveillance and infections antimicrobials OIE Objective 1: Improve Objective 2: Objective 3: Support Objective 4: The OIE Strategy on awareness and un- Strengthen knowl- good governance Encourage imple- Antimicrobial Resistance derstanding edge through sur- and capacity buil- mentation of inter- and the Prudent Use of veillance and re- ding national standards Antimicrobials 2016 search http://www.oie.int/fileadmin/ Home/eng/Media_Center/ docs/pdf/PortailAMR/EN_OIE- AMRstrategy.pdf Codex Alimentarius Code of Practice Guidelines for General Principles Code of Practice Several Codes of hy- Codex texts on foodborne anti- to Minimize Risk Analysis of Food Hygiene on Good Animal gienic practices for microbial resistance 2015 and Contain of Foodborne Feeding different commod- 55 Antimicrobial Antimicrobial ities (e.g. milk and http://www.fao.org/ Resistance (2005) Resistance (2011) milk products) fao-who-codexalimentarius/ standards/thematic-compila- tions/en/ FAO Focus Area 1: Focus Area 2: Focus Area 4: Focus Area 3: The FAO action plan on Improve awareness Develop capacity Promote good prac- Strengthen gover- Antimicrobial Resistance 2016- on Antimicrobial for surveillance and tices in food and ag- nance related to an- 2020 Resistance and re- monitoring riculture systems timicrobial use NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE 2017–2021 lated threats of Antimicrobial and the prudent use and Antimicrobial http://www.fao.org/3/a- Resistance and an- of antimicrobials Resistance in food i5996e.pdf timicrobial use in and agriculture food and agriculture Nordic Council 12 Initiatives. 6. Improving the 3. Collation of 1. Reduction of the 2. Rationalisation 4. Collation of kno- 7. Political pressure Nordic co-operation on com- dissemination and knowledge of dis- need for antibiotic of the use of anti- wledge of the opti- and dialogue via bating antimicrobial resistance. sharing of best tribution patterns treatment through biotics for the treat- mal use of existing international A white paper outlining new practices and the spread of vaccination and ment of humans antibiotics co-operation Nordic initiatives, 4.4.2017. antimicrobial re- prevention of in- and animals and vaccines http://norden.diva-portal.org/ sistance fection smash/get/diva2:1086062/ 5. Providing incenti- FULLTEXT01.pdf ves for the develop- ment of new health technologies, in- novative medicines and vaccines PUBLICATIONS OF THE MINISTRY OF SOCIAL AFFAIRS AND HEALTH 2017:12

Appendix 2 National legal provisions related to communicable diseases (www.finlex.fi) Food Act Act and Decree on Private Healthcare Act and Decree on Animal Welfare Act on the National Supervisory Authority for Animal Diseases Act Welfare and Health ValviraAct on the Openness Act on Specialised Medical Care of Government Activities Act on Administrative Courts Medicines Act and Decree Personal Data Act and Decree Act on the Treatment of Persons in Police Custody Aviation Act Patient Injuries Act Waste Act and Decree The Criminal Code of Finland Act on the Administrative Experiment in Kainuu Health Insurance Act and Decree Primary Health Care Act and Decree Communicable Diseases Act and Decree Act on the State Subsidies to Municipalities Healthcare Act Act and Decree on the Municipality of Residence Health Protection Act and Decree Act on Veterinary Border Controls Act on Court Fees Act on Animal Medication Detention Act Act on the National Institute for Health and Welfare Occupation Accidents, Injuries and Diseases Act and Act on Municipal Officials Decree Act and Decree on Children’s Day-care Occupational Health Care Act Act on the Finnish Medicines Agency FimeaAct on Occupational Safety and Health Act the Status and Rights of Patients Government Decree on the Investigation of Act and Decree on the Customer Charges in Social Epidemics Spread via Food and Water Welfare and Healthcare Government Decree on the Prohibition of Use of Act on Healthcare Professionals Certain Pharmaceutical Substances in Animals Act and Decree on Medical Devices and SuppliesAct Government Decree on the Advisory Committee of and Decree on National Personal Data Files on Communicable Diseases Healthcare Professionals Government Decree on the Zoonosis Centre 56 MINISTRY OF SOCIAL AFFAIRS AND HE ALTH ISSN PDF 1797-9854 ISBN PDF 978-952-00-3965-3