Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP)

October 2018 Government of Kerala Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) © Copyright Government of Kerala October 2018 Kerala Antimicrobial Resistance Strategic Action Plan 3 Table of Contents Message from Chief Minister ...................................................................................... 4 Message from Health Minister .................................................................................... 5 Acknowledgements ....................................................................................................... 6 Preface .............................................................................................................................. 7 Acronyms and abbreviations ....................................................................................... 8 Background ...................................................................................................................... 9 State Workshop on Antimicrobial Resistance ...................................................... 13 Kerala Antimicrobial Resistance Strategic Action Plan ....................................... 15 Strategic priority 1 – Awareness and Understanding............................................. 16 Focus area: Communications and IEC ............................................................................. 16 Focus area: Education and Training .................................................................................. 17 Strategic priority 2 – Knowledge and Evidence ....................................................... 21 Focus area: Laboratories ..................................................................................................... 21 Focus area: Surveillance ....................................................................................................... 21 Strategic priority 3 – Infection Prevention and Control ....................................... 24 Focus area: Infection Prevention and Control in human health ................................ 24 Focus area: Animal feed & food ......................................................................................... 25 Focus area: Environment ..................................................................................................... 26 Strategic priority 4 – Optimising Use of Antibiotics .............................................. 27 Focus area: Regulations ........................................................................................................ 27 Focus area: Hospitals and healthcare institutions ......................................................... 28 Focus area: Veterinary and aquaculture .......................................................................... 29 Focus area: Surveillance of antimicrobial use ................................................................. 29 Strategic priority 5 – Research and Innovations ...................................................... 31 Focus area: Research on AMR ........................................................................................... 31 Focus area: Innovations ........................................................................................................ 32 Strategic priority 6 – Collaborations.......................................................................... 34 Focus area: Public private partnership ............................................................................. 34 Focus area: State disease control programmes ............................................................. 34 Monitoring and Evaluation framework ................................................................... 35 Kerala Antimicrobial Resistance Strategic Action Plan 4 Message from Chief Minister I am happy to launch the Kerala Antimicrobial Resistance Strategic Action Plan developed by the Department of Agriculture, Animal Husbandry, Fisheries, Environment and Health & Family Welfare of the Government of Kerala in partnership with many other stake holders. This is the first of its kind prepared by any state in India. It recognizes the linkage between different sectors captured in the “One health” policy announced by World Health Organization. I am happy that all the concerned departments under the Government of Kerala have come together in the true spirit of “One Health” and developed this document. I hope that it will become an inspiration and guidance to other states to develop and implement similar Action Plans. Antimicrobial resistance (AMR) is a global issue and actions are needed at every level to combat it. But action at the State, District, Sub-district and institution level will be critical. The Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) outlines the strategic priorities and activities to achieve the objectives, outputs and outcomes, right from awareness and knowledge, surveillance, optimizing antimicrobial use including antimicrobial stewardship, research to infection prevention and control. Kerala is considered a consumer State for pharmaceuticals with a total consumption of drugs in the State estimated to be around INR 20,000 crores per annum. Therefore, rational use of pharmaceuticals is very important for Kerala. I believe that the overuse and misuse of antimicrobials can be curtailed with the help of this action plan. I observe that research studies and initiatives are also underway to establish the role of phytochemicals and natural antimicrobial substances as a means to fight antibacterial resistance, and may offer a way forward in AMR containment. The sustainability of KARSAP depends on the attitude of all the stakeholders in the programme and the extent to which it is implemented. I look forward to the plan being implemented efficiently at all levels where antibiotics are used. I am sure, our State will become a model to the entire nation to develop their own strategies against this global issue. I wish all success to stakeholders in their endeavour to implement this plan and to minimise Antimicrobial Resistance in Kerala. Pinarayi Vijayan Hon’ble Chief Minister Kerala Antimicrobial Resistance Strategic Action Plan 5 Message from Health Minister It is a moment of pleasure and pride to launch the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP), which is the first of its kind in India, and may be in the South-East Asia Region. Antimicrobial Resistance (AMR) is a serious global public health threat in this century. Major drivers of AMR include inappropriate use of antimicrobials in healthcare as well as in animal husbandry, especially those used for non-therapeutic purpose like growth promotion and in agriculture and fisheries. AMR cannot be completely eradicated however, collaborative and comprehensive action needs to be taken to reduce the prevalence and spread of antimicrobial resistance. In order to minimize the development of AMR and to maintain the effectiveness of existing antimicrobials, an integrated overarching “One Health” approach is essential in addressing this complex and challenging issue. The KARSAP has been developed involving multiple sectors and it addresses a wide range of activities required to tackle AMR problem effectively. I am glad to acknowledge the support provided by the World Health Organisation Country Office for India in the development and implementation of KARSAP, which requires commitment and complementary efforts from all related sectors including health professionals – which include doctors, nurses, microbiologists, pharmacologists, researchers – veterinarians, farmers those involved in fisheries and all other related stakeholders. Educational campaigns and awareness of AMR should also be addressed to all levels of Society. I would like to applaud all the parties involved either directly or indirectly in developing and upraising this action plan including national government and partners like WHO Country Office for India. I hope that this action plan will provide guidance towards responsible use of antimicrobial agents in the efforts to combat AMR and preserve the efficiency of these precious drugs for the present and the future generation. K.K. Shailaja Teacher Hon’ble Minister for Health &Family Welfare Kerala Antimicrobial Resistance Strategic Action Plan 6 Acknowledgements The guidance and oversight provided by Shri Pinarayi Vijayan, Hon‟ble Chief Minister, Smt. K.K. Shailaja Teacher, Hon‟ble Minister for Health, Shri Rajeev Sadanandan, Additional Chief Secretary (Health), Shri MC Dathan, Scientific Advisor to Hon‟ble Chief Minister, Shri Lav Agarwal, Joint Secretary, Ministry of Health and Family Welfare, and senior officials from National Centre for Disease Control to develop the Kerala Antimicrobial Resistance Strategic Action Plan is gratefully acknowledged. This document is based on inputs provided by officials and experts from Kerala‟s State Departments of Agriculture Development and Farmers Welfare, Animal Husbandry, Environment, Fisheries, Health and Family Welfare. Active contributors include the experts from Government Medical College Thiruvananthapuram, Rajiv Gandhi Centre for Biotechnology, State Laboratory For Live Stock Marine and Agri Products, State Pollution Control Board, State Drug Controller, Kerala Veterinary and Animal Sciences University, State Public Health Laboratory, Central Institute of Fisheries and Technology Kochi, Amrita Institute of Medical Sciences and Research Centre, Kerala branch of Indian Medical Association, Aster Medicity, Apollo hospital Chennai, ReAct South Asia and state universities and institutions in Kerala. The following organizations were engaged through a call for partnerships for implementation of KARSAP – Becton Dickinson, Beckman Coulter, bioMerieux, MSD/Merck, DSM Sinochem Pharmaceuticals and Centre for Science and Environment. Technical coordination and documentation support was provided by World Health Organization Country Office for India. Kerala Antimicrobial Resistance Strategic Action Plan 7 Preface The Kerala Government identified antimicrobial resistance (AMR) as a priority few years back. Since then Kerala has been working on its containment through the State AMR committee. A number of activities have been organized for AMR containment in the state including awareness generation, AMR surveillance through laboratory data, infection prevention and control and facilitating pilot research projects for AMR containment. Since October last year, the approach for AMR containment has been widened, involving stakeholders from animal husbandry, agriculture, food, environment, research and civil society, under the umbrella of a comprehensive One Health approach. This led to a revision of the membership of the State AMR committee and developing a new set of strategies on AMR surveillance, prevention and research. The Department of Health and Family Welfare is closely monitoring the AMR situation in collaboration with all stakeholders. Focal points for key focus areas have been identified for overall coordination and surveillance, research, infection prevention and control, antimicrobial stewardship and private sector. The State also formally engaged with the private sector and civil society through a successful call for expression of interest leading to a memorandum of understanding in collaborating with the Government of Kerala for AMR containment in the state. More and more institutions have become partners in regular surveillance and reporting. Regular meetings of the State AMR committee are being organized to monitor the AMR situation and the activities undertaken for AMR containment in the state and areas identified for research on extent and prevention of AMR. We realize that with this action plan we are committing ourselves to achieving specific results in an unchartered territory. This will involve calibration of strategies and even their outright revision based on our experience of implementing this action plan. But I hope that this will motivate all the stakeholders to take forward the measures they have committed, to contain the public health threat of AMR in Kerala in the spirit of One Health. Rajeev Sadanandan Additional Chief Secretary, Department of Health & Family Welfare Kerala Antimicrobial Resistance Strategic Action Plan 8 Acronyms and abbreviations AMR Antimicrobial Resistance API Association of Physicians of India ASP Antimicrobial Stewardship Program DHS DirectorHealth Services DME DirectorMedical Education DMO District Medical Officer FSSAI Food Safety and Standards Authority of India GMCK Government Medical College Kozhikode GMCT Government Medical College Thiruvananthapuram HAI healthcare associated infection IAP Indian Academy of Pediatrics ICU intensive care unit IEC information education and communication IMA Indian Medical Association IPC infection prevention and control IPHA Indian Public Health Association IVRI Indian Veterinary Research Institute KAP knowledge attitude and practice KARSAP Kerala Antimicrobial Resistance Strategic Action Plan KVASU Kerala Veterinary and Animal Sciences University LSG local self government institutions NABH National Accreditation Board for Hospitals and HealthcareProviders NABL National Accreditation Board for Testing and Calibration Laboratories NAP-AMR National Action Plan on Antimicrobial Resistance OTC over-the-counter RGCB Rajiv Gandhi Centre for Biotechnology SOP standard operating procedures WHO World Health Organization Kerala Antimicrobial Resistance Strategic Action Plan 9 Background Antimicrobial Resistance (AMR) is a global public health problem. Eventhough there are many drivers of antibiotic resistance, the most dangerous trends contributing to rising AMR apart from the inappropriate use of antibiotics in humans include antibiotic use for growth promotion and disease prevention in animals, horticulture and fisheries. The use of animal manure in soil and inadequate treatment of effluents containing antibiotic residues from pharmaceutical industry, healthcare facilities and farms also contributes to the problem of increasing AMR. The Government of Kerala is committed to take suitable action to address antimicrobial resistance in the State by involving all stakeholders to develop and implement a State Action Plan on AMR, which will be in alignment with the National Action Plan on Antimicrobial Resistance (NAP-AMR) and the Global Action Plan on Antimicrobial Resistance (GAP-AMR). Inter-sectoral collaboration and a One Health Approach are crucial and hence integrated in the government‟s approach. Creating awareness on AMR among cross sectoral stakeholders is important for AMR containment. The Government of Kerala has been involved in creating awareness and developing skills for AMR containment among the medical community in Kerala. Awareness classes have been held at all Government medical colleges in Kerala for faculty and students. The focus of these classes is to emphasize the importance of rational antibiotic use, infection control practices and need to follow institutional antibiotic policy. Participation from private sector and professional bodies, especially Indian Medical Association has been encouraging towards drafting the policy and training the trainers. Strengthening laboratory capacity for AMR surveillance and collating the data on AMR is essential for assessing baseline AMR burden and providing evidence based information for action. As of now, Kerala has initiated AMR surveillance programme in government teaching hospitals and many tertiary care private hospitals also carry out surveillance. Since food of animal origin also represents Kerala Antimicrobial Resistance Strategic Action Plan 10 the major route of human exposure to foodborne pathogens, AMR surveillance in animals and fishes is as critical as it is in human health. Currently, Government Medical Colleges and General Hospitals are engaged in surveillance of infections of public health importance namely blood stream infection, skin and soft tissue infection, respiratory tract infection, and urinary tract infection and also track six pathogens of public health importance (E. coli, Klebsiella spp., Acinetobacter spp., Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus spp.). Government Medical College Thiruvananthapuram (GMCT) is collating data on AMR surveillance fromall teaching hospitals in the State to track AMR trends over time. Government will expand the surveillance to district, secondary and primary level hospitals in order to get more community datato understand the burden of AMR in the community. When the government system is stabilized private hospitals will also be invited to join the data collection system Application of good infection prevention and control (IPC) measures across human health, animal health and agriculture also helps to prevent infections and limit use of antibiotics. Steps have been taken to tackle AMR at all government medical colleges in Kerala, which include scaling up of infection control program to prevent spread of antibiotic resistant organisms. Healthcare associated infection (HAI) rates with respect to ventilator associated pneumonia, catheter associated blood stream infection, catheter associated urinary tract infections and surgical site infections are being calculated in 20 intensive care units (ICU) and 8 high dependency units at Medical College Hospital Thiruvananthapuramin addition to the NABH accredited institutions in the State who submit data on healthcare associated infections (HAIs) each month to NABH for the national database. HAI rate calculation is going to be extended to the remaining 14 ICUs and 8 high dependency units at Medical College Hospital Thiruvananthapuram. Infection control nurses and link nurses have been identified and trained in all government medical colleges in Kerala and soon HAI rates will be calculated in all medical colleges. It is proposed to establish a hub of infection surveillance in the state, with Department of Microbiology at GMCT as the nodal centre. All surveillance data from various government medical colleges Kerala Antimicrobial Resistance Strategic Action Plan 11 will be forwarded to Department of Microbiology at GMCT, where the trends and rates of infections and AMR will be collated and analysed. Application of good IPC measures to animal husbandry is important to reduce antimicrobial residues in environment. Kerala State Pollution Control Board recommends adherence to good farm management practices for infection control among flocks.IPC measures also include issuance of improved biosecurity guidelines by Central Poultry Development Organisation for farm implementation and promotion of antibiotic alternatives (such as vaccination).The threat of action under phytosanitary conditionalities by fish importing countries has led to fisheries department to monitor the use of antibiotics in fish hatcheries and farms. Kerala is considered as a consumer State for pharmaceuticals with a total consumption of drugs in the state at around 20,000 crores per annum, with antibiotics making up 20% of the total drugs consumed annually in the state. Poultry farmers in Kerala also use a variety of antibiotics either as growth promoters or for controlling infections. Many prescription medications used for human and animal health ultimately find their way into the environment and can affect the health and behaviour of animals. Drugs Control Department has a very significant role to play by way of regulatory action for optimizing the use of antibiotics, preventing sale of spurious and not-of-standard-quality (NSQ) drugs, and over-the-counter (OTC) sale, and adherence to the Red line campaign of Government of India. GMCT has also initiated Antibiotic Stewardship Program (ASP) to ensure that the right drug gets prescribed at the right time, in the right dose, for right duration for the right patient at all government medical colleges in Kerala. For that purpose antibiotic stewardship committees have been started at all government medical colleges in Kerala. Antibiotic prescription audit has been started in all government medical colleges under department of pharmacology. General Hospital Ernakulam (accredited by the National Accreditation Board for Hospitals and Healthcare Providers [NABH]) has been running a very effective ASP for the last two years. All the NABH accredited corporate hospitals in the state have good AMR surveillance as well as ASP programs which have demonstrated decrease in consumption of high end antibiotics, reduction in length of stay, mortality and cost of care. Kerala Antimicrobial Resistance Strategic Action Plan 12 The importance of research and innovations cannot be over emphasized. As the world is running out of effective antibiotics to fight even simple infections, alternate strategies and new molecules need to be discovered at the earliest. RGCB is the research partner for AMR containment activities in the State. Research is also underway to establish the role of phytochemicals and natural antimicrobial substances as a means to fight antibacterial resistance. Rajiv Gandhi Centre for Biotechnology (RGCB), Thiruvananthapuram, Kerala (www.rgcb.res.in), a premier national research institute, is exclusively devoted to research in molecular biology and biotechnology. Various challenges in development and implementation of Kerala State Action Plan on AMR may include human resources (numbers and skills), standardisation of evidence based medicine practise across all healthcare organisations, standardisation of microbiology laboratories, role of anthropogenic activities in contaminating the natural water bodies, OTC sale of antibiotics, absence of antibiotic residue control program, and traceability problems with food of animal origin. However, despite these challenges the Government of Kerala is extremely committed and supportive of activities and proposals of all relevant stakeholders. Besides, strong collaborations and commitment of stakeholders across human health, animal health, food/agriculture and environment gives a positive direction to success ahead if these efforts are sustained over the coming years. http://www.rgcb.res.in)/ Kerala Antimicrobial Resistance Strategic Action Plan 13 State Workshop on Antimicrobial Resistance The Kerala State Workshop on Antimicrobial Resistance was organized by the Department of Health and Family Welfare, Government of Kerala at the State Health Systems Resource Centre in Thiruvananthapuram on 17 October 2017. The aim of the workshop was to share information on AMR and its containment in Kerala and brainstorming to initiate development of the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP), in alignment with the NAP-AMR. The workshop brought together stakeholders from human health, animal health, agriculture,environment and research, to discuss the importance of a „One Health‟ approach in containing AMR and development of KARSAP. Following an information sharing session, the participants were segregated into teams based on their domain of expertise to reflect on strategic activities for collaborative containment of AMR, with a One Health approach. The groups reflected on the following priority areas: (1) Awareness and understanding – communications and training (2) Knowledge and evidence – laboratories and surveillance (3) Infection prevention and control – human health, animal/food and community (4) Optimizing use of antibiotics – regulations and antibiotic consumption, antimicrobial stewardship in humans and animals (5) Research andinnovations (6) Collaborations The workshop had active engagement of all stakeholders and key takeaway messages and follow-up action points from the workshop include the following:  RGCB volunteered to host a meeting to define the research priorities under Kerala‟s State Action Plan on AMR, and to lead development of research proposals by January 2018.  Prioritization of AMR surveillance activities Kerala Antimicrobial Resistance Strategic Action Plan 14 o Private colleges and laboratoriesaccredited by the National Accreditation Board for Testing and Calibration Laboratories (NABL), to feed their AMR data into State level o WHONET to be used for data entry on AMR across human health, veterinary sector and food laboratories o The Department of Microbiology GMCT to collate the data sent in by laboratories participating in the surveillance  Hospital Infection Control programs to be mainstreamed at all levels  Review need for microbiology laboratories‟ automation to guide clinical use of antibiotics  Regulatory bodies to control use of antibiotics o State Drug Controller to suggest a mechanism o Review use of electronic prescriptions (similar to National Health Service, UK)  World Health Organization Country Office for India was requested to provide technical support for development and implementation of State Action Plan on AMR in Kerala  A multi-disciplinary working group to be formed for AMR containment in Keralawith representatives from all key stakeholders, including health department, animal husbandry, fisheries, agriculture, pollution control board, drug regulator, food safety, science & technology, Ayurveda Yoga Unani Siddha Homeopathy (AYUSH), research institutes, private sector, etc.  Suggestion to create an operational team (core working group or secretariat) was proposed to carry out routine day to day operational activities towards development and successful implementation of the AMR action plan in Kerala The next section describes the focus areas, objectives, activities and key stakeholders, as proposed by the participants for each strategic priority, at the Kerala State Workshop on Antimicrobial Resistance. Kerala Antimicrobial Resistance Strategic Action Plan 15 Kerala Antimicrobial Resistance Strategic Action Plan The Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) has 6 strategic priorities: The following are the focus areas of the strategic priorities under KARSAP: 1. Awareness and understanding 2. Knowledge and evidence 3. Infection prevention and control 4. Optimizing use of antibiotics 5. Research and innovations 6. Collaborations 1. Awareness & understanding Communication & IEC Education & Training 2. Knowledge & evidence Laboratories Surveillance 3. Infection prevention & control IPC in human health Animal feed & food Environment 4. Optimise use of antibiotics Regulations Hospitals & healthcare Veterinary & aquaculture Surveillance of AM use 5. Research & Innovations Research Innovations 6. Collaborations Public private partnerships Disease control programs Kerala Antimicrobial Resistance Strategic Action Plan 16 Strategic priority 1 – Awareness and Understanding Aim: Improve awareness and understanding of AMR through effective communication, education and training Focus area: Communications and IEC Objective: To improve the awareness among general public on antibiotic abuse, antimicrobial resistance, antibiotics in food, labelling of food derived from animals and the One Health approach using standardized information, education and communication(IEC) material like short videos, pamphlets, animations, booklets, posters articles in media etc. 1.1. Create a framework for engagement using social media (Department of Health and Family Welfare, Department of Electronics & Information Technology, Kerala State Information Technology Mission, State Council of Educational Research and Training)Timeline: 3 years 1.2. Organize awareness raising events to celebrate the World Antibiotic Awareness Week 1.3. Ensure consumer awareness on antibiotics in food and AMR, labelling of food from animals raised with/without antibiotics and responsible use of antimicrobials 1.4. Create tools facilitating thorough risk communication in the areas of livestock production,aquaculture and food hygiene. 1.5. Launch an online platform/framework to communicate information on One health approach to AMR Objective: To improve the awareness among school childrenabout antibiotic abuse, infection prevention and antimicrobial resistance using tailored educational material integrated into school curricula 1.6. Develop and integrate educational resourceson AMR into school curriculum (Department ofCommunity Medicine at medical Kerala Antimicrobial Resistance Strategic Action Plan 17 colleges,Department of General Education, civil society groups,WHO)Timeline: 1 year 1.7. Celebrate antibiotic awareness week in schools, colleges and all healthcare organisations in the State (Department of Health and Family Welfare, Department of General Education anduniversities)Timeline: 3 years Objective: To organize mass sensitization programmes in schools and colleges, using already existing engagement platforms like National Service Scheme, National Cadet Corps, etc. 1.8. Formulate and pilot IEC material on antibiotic use and AMR (Department ofCommunity Medicine at medical colleges,mass media, local self-government institutions, Kudumbashree) Timeline: 3-6 months Focus area: Education and Training Objective: To formulate a system of tailored training programmes on AMR and IPC for doctors at all levels of the health care delivery system. 1.9. Formulate offline and online training programmes for doctors at all levels (DirectorMedical Education[DME],Director Health Services[DHS], Kerala University of Health Sciences (KUHS), National Informatics Centre Kerala, ReAct, Kerala state branches of IndianMedical Association [IMA], Indian Public Health Association [IPHA]) Timeline: 3 years 1.10. Study/research on changes in knowledge, attitude and practice (KAP), following implementation (Department ofCommunity Medicine at medical colleges,Department of Health and Family Welfare) Timeline: 5 years Objective: To plan and implement university level training programmes for undergraduate and postgraduate level students, house-surgeons and faculty, under the aegis of Kerala University of Health Sciences (KUHS) Kerala Antimicrobial Resistance Strategic Action Plan 18 1.11. Formulate and implement customised training programmes for undergraduate and postgraduate students (Kerala University of Health Sciences[KUHS],Department of Microbiology at medical colleges, WHO) Timeline: 5years 1.12. Study/Research on changes in KAP among undergraduate & postgraduate students and faculty, following implementation of training programs (Department ofCommunity Medicine at medical colleges,Department of Health and Family Welfare) Timeline: 5 years Objective: To train all the pharmacists, nurses and supporting staff, in antibiotic protocols, antibiotic abuse and antibiotic resistance 1.13. Training programme for pharmacists, nurses and support staff (StateDrug Controllers, Pharmacy and Nursing colleges,Kerala Government Pharmacists' Association, other pharmacists‟ associations, Nursing association)Timeline: 3years 1.14. Study/Research on changes in KAP among pharmacists, nurses and support staff, following implementation of training programs (Department ofCommunity Medicine at medical colleges,Department of Health and Family Welfare) Timeline: 5 years Objective: To devise a system for training other users of antibiotics, like food animal farmers, veterinary doctors (and students), farmers (of food animal)and fisheries professionals 1.15. Targeted training programme for farmers, veterinarians (and veterinary students), and fisheries professionals(Agriculture Development & Farmers' Welfare Department,Fisheries Department,Animal Husbandry Directorate,Department of Health and Family Welfare, Central Institute of Fisheries Technology (CIFT), Kerala Veterinary and Animal Sciences University [KVASU], Kerala University of Fisheries and Ocean Studies)Timeline: 5years 1.16. Incorporate AMR education in curriculum and develop continuing education/training programs related to AMR for professionals in Kerala Antimicrobial Resistance Strategic Action Plan 19 veterinary medicine, fisheries and agriculture (Agriculture Development & Farmers Welfare Department,Fisheries Department, Animal Husbandry Directorate, Department of Health and Family Welfare, Kerala Veterinary and Animal Sciences University [KVASU], Kerala University of Fisheries and Ocean Studies) Timeline: 5 years 1.17. Study/Research on changes in KAP among farmers, veterinarians, and fisheries professionals, following implementation of training program (Department ofCommunity Medicine at medical colleges,Department of Health and Family Welfare) Timeline: 5 years Objective: To build capacity among those working in environment and allied agencies, for surveillance of antibiotic residues and antimicrobial resistance in the environment 1.18. 1.19. Capacity building workshops for personnel from Environment and Pollution Control Boardand allied agencies for surveillance of antibiotic residues and AMR in the environment (Department of Environment, Department of Health and Family Welfare, Department of Community Medicine at medical colleges, Central Institute of Fisheries Technology (CIFT), Kerala State Pollution Control Board)Timeline: 3 years Study/Research on changes in KAP among those working in environment, pollution control board and allied agencies, following implementation of training program (Department of Community Medicine at medical colleges, Department of Environment, Department of Health and Family Welfare) Timeline: 5 years Key stakeholders: Department of Health and Family Welfare, Department of Agriculture Development & Farmers' Welfare, Animal Husbandry Directorate, Fisheries Department, Department of Environment, DirectorHealth Services [DHS], DirectorMedical Education [DME], General Education Department, State Drugs Control Department, Electronics & Information Technology Department, Kerala State Pollution Control Board, National Informatics Centre Kerala, Department of Community Medicine at medical colleges, Department of Microbiology at medical colleges, Kerala University of Health Sciences, Indian Public Health Association [IPHA], Kerala state branch/chapter of Indian Medical Association Kerala Antimicrobial Resistance Strategic Action Plan 20 [IMA], private sector hospitals, Kerala State Information Technology Mission, Central Institute of Fisheries Technology (CIFT), Kerala University of Fisheries and Ocean Studies, Kerala Veterinary and Animal Sciences University [KVASU], Kerala Government Pharmacists' Association, other pharmacists‟ associations, State Council of Educational Research and Training Kerala, Kudumbashree, local self-government institutions, mass media, universities, ReAct, WHO, civil society groups working on AMR… Kerala Antimicrobial Resistance Strategic Action Plan 21 Strategic priority 2 – Knowledge and Evidence Aim: Strengthen knowledge and evidence for containment of AMR through surveillance Focus area: Laboratories Objective: Strengthening of microbiology laboratories to detect antimicrobial resistance 2.1. Establish and standardize microbiology laboratories in all district hospitalswith medical microbiologists (MD); with all laboratories enrolled in External Quality Assurance Scheme (DME, DHS, State Health Mission)Timeline: 1 year 2.2. Standardized laboratories in veterinary sector in every district (Animal Husbandry Directorate)Timeline: 1year 2.3. State level standard operating procedures (SOP) for collection, storage, transportation, processing and quality assurance (DME, DHS)Timeline: 1year 2.4. Establish data collection and collaboration at district levels (DME, DHS, Department of Microbiology GMCT)Timeline: 1year 2.5. Upgradation of microbiology laboratories at medical colleges and districts - automated systems for identification and antimicrobial sensitivity testing(DME, DHS) Timeline: 1year 2.6. Strengthen human resources for laboratories in human and veterinary sectors(DHS, Animal Husbandry Directorate) Focus area: Surveillance Objective: Standardize and strengthenAMRsurveillancein Kerala 2.7. Establish state referral laboratory at Department of Microbiology GMCT 2.8. State Public Health Laboratory Thiruvananthapuramand General Hospital Ernakulamidentified as two regional centres for AMR surveillance in district/general hospitals; all laboratories in the Kerala Antimicrobial Resistance Strategic Action Plan 22 2.9. 2.10. 2.11. 2.12. 2.13. network to be assessed using a standard questionnaire followed by a site visit. AMR surveillance to be initiated at all levels for 6 pathogens (E. coli, Klebsiella spp., Acinetobacter spp., Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus spp) in 4 samples – blood, urine, pus/exudate, respiratory specimens Animal surveillancefor sample-bug-drug combinations as per guidelines issued by the Food and Agriculture Organization of the United Nations(Chief Disease Investigation Office, Palode, Thiruvananthapuram; four apex laboratories at Palode, Thiruvalla, Ernakulam and Palakkad; KVASU, Wayanad and Ernakulam laboratory shall collate, analyse and share data with Director Animal Husbandry) Surveillance in food animals and their products for sample-bug-drug combinations (State Laboratory for Livestock Marine and Agri Products, Maradu, Ernakulam) Surveillance in fisheries for sample-bug-drug combinations (Central Institute of Fisheries Technology [CIFT], Kochi) Surveillance in dairy products and food for sample-bug-drug combinations (Council for Food Research and Development laboratory at Konni) 2.14. Develop and implement standards for antibiotic residues in food (from animals), and in waste(Department of Agriculture, Central Institute of Fisheries Technology, State Pollution Control Board) 2.15. Strengthen the state antibiotic residue control plan in animal productsby Animal Husbandry Directorate 2.16. Strengthen the state antibiotic residue control plan in food by Food Safety and Standards Authority of India(FSSAI) 2.17. Surveillance and monitoring of AMR in aquatic and terrestrial environments (all relevant stakeholders including Central Institute of Fisheries Technology) 2.18. Develop and adopt standards for antibiotic residues in waste generated from farms, factories, human health care, veterinary care Kerala Antimicrobial Resistance Strategic Action Plan 23 and fisheries settings (all relevant stakeholders including Central Institute of Fisheries Technology) 2.19. Strengthen the state antibiotic residue control plan in environment done by Kerala State Pollution Control Board 2.20. Identify nodal persons in all sectors. State level inter-sectoral committee will meet under chairmanship of Directorate of Health Services in every quarter 2.21. Establish separate AMR databases for human, animal, food and environment 2.22. Strengthen resources for surveillance of AMR and antibiotics/residues in all sectors – human, veterinary, agriculture, crops, food, fisheries, and environment 2.23. Establish and implement a comprehensive One Health AMR surveillance system Key stakeholders: DirectorHealth Services [DHS], DirectorMedical Education [DME], Animal Husbandry Directorate, Department of Microbiology GMCT, State Public Health Laboratory Thiruvananthapuram, General Hospital Ernakulam, Chief Disease Investigation Office Palode, apex laboratories (Palode, Thiruvalla, Ernakulam, Palakad), Kerala Veterinary and Animal Sciences University (KVASU), State Laboratory for Livestock Marine and Agri Products Ernakulam, Central Institute of Fisheries Technology (CIFT) Kochi, Council for Food Research and Development laboratory Konni, Kerala State Pollution Control Board, Food Safety and Standards Authority of India, State Health Mission… Kerala Antimicrobial Resistance Strategic Action Plan 24 Strategic priority 3 – Infection Prevention and Control Aim: Reduce the incidence of infection through effective infection prevention and control (IPC) Focus area: Infection Prevention and Control in human health Objective: Reduction of healthcare associated infections (HAI) rates by 20%of the existing rate by one year and 50% by three year and attaining international benchmark by five years 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. Develop and implement IPC programme, with standard operating procedures (SOP) Ensure appropriate facilities for isolation and supplies for standard precautions (individual institutions) Strengthen medical and surgical asepsis (Hospital Infection Control Department) Strengthen sterilization & disinfection (Hospital Infection Control Committee & Central Supply Sterilization Department) Strengthen immunization coverage/programme Establish policyfor occupational exposures including sharps and blood/body fluids exposure Ensure administrative oversight of IPC activities (Hospital Infection Control Committee, Infection Control Team, Rapid Response Team, Scientific Advisory Panel) Objective: Hand hygiene compliance 80% by one year and 100% by three years 3.8. Strengthen and improve hand hygiene in hospitals(Infection Control Team, HICC) Objective: Adherence to Antibiotic Policy and Antimicrobial Stewardship Programme 3.9. Ensure appropriate antibiotic prophylaxis and use (Hospital Antimicrobial Stewardship Committees/Teams) Kerala Antimicrobial Resistance Strategic Action Plan 25 Objective: Ensure HAI surveillance and regular monitoring through an evaluation framework for IPC 3.10. associated 3.11. Establish surveillance of common healthcare infections (Hospital Infection Control Committees) Monitor the IPC programme (Department of Health) Objective:Reducing environmental contamination with multi-drug resistant pathogens& antimicrobial residues 3.12. 3.13. 3.14. 3.15. Identify environmental sources of infection (Kerala State Pollution Control Board, LSG) Improve housekeeping and environment management (Housekeeping department & engineering department at hospitals) Ensure appropriate bio-medical waste management (individual institutions) Strengthen facility infrastructure including environment controls and sewage treatment plant (Kerala State Pollution Control Board, health institutions) Focus area: Animal feed & food Objective: Reducing incidence of infection through effective infection prevention and control in animals 3.16. Ensure compliance to routine immunization and biosecurity measures 3.17. Ensure compliance to sterilization & disinfection practices 3.18. Ensure compliance to IPC practices during production/processing of food& food storage 3.19. Establish statutory regulatory body for animal health 3.20. Developstandard operating procedures (SOP) 3.21. Develop and implement infection prevention and control programs in veterinary settings and animal husbandry. Kerala Antimicrobial Resistance Strategic Action Plan 26 Focus area: Environment Objective: Reducing incidence of infection through effective infection prevention and control in environment 3.22. 3.23. 3.24. 3.25. 3.26. 3.27. 3.28. 3.29. 3.30. Identify sources of AMR (Kerala State Pollution Control Board, LSG) Collect baseline data (Kerala State Pollution Control Board, LSG) Ensure routine monitoring and surveillance Trace source of infection in the environment to prevent contamination of environment Establishstatutory regulatory body (StateGovernment) Developstandard operating procedures (SOP) Develop policy on registration and licensing of farms, factories, slaughterhouses, fish/meat/dairy processing units, animal feed manufacturing units, health care facilities and veterinary care units Develop appropriate biosecurity guidelines, siting guidelines and Standard Operating Procedures (SOPs) on waste management for farms, feed manufacturers, slaughter houses, food processing units, health and veterinary care facilities, sewage treatment plants and good manufacturing practices (GMPs) for fish/meat/dairy processing units Adopt less risky litter/manure management approaches such as biogas generation (in-house plants or common plants),proper composting for treatment of litter/manure under supervision Key stakeholders: Hospital Infection Control Department (Infection Control Committee, Infection Control Team), Hospital Antimicrobial Stewardship Committees/Teams, housekeeping department and engineering department at hospitals, Central Supply Sterilization Department, Kerala State Pollution Control Board, Central Institute of Fisheries Technology (CIFT), local self-government institutions (LSG), individual institutions, health institutes, Government… Kerala Antimicrobial Resistance Strategic Action Plan 27 Strategic priority 4 – Optimising Use of Antibiotics Aim: Optimize the use of antimicrobial agents in health, animals and food Focus area: Regulations Objective: Stepwise introduction to reduce OTC sale of drugs 4.1. Announce, notify and issue circulars to pharmacies 4.2. Prepare training modules/IEC and conduct awareness/skill development campaignfor regulators, custom officials, distributors, pharmacists, licensees and pharmacy students (State Drugs Control Department, Kerala State Pharmacy Council) 4.3. Conduct educationsessions(Kerala State Pharmacy Council, pharmacists associations, IMA, Association of Physicians of India [API], Indian Academy of Paediatrics [IAP]) 4.4. Ensure compulsory attendanceat 6-monthly educational sessions(Kerala State Pharmacy Council) 4.5. Conduct public awareness activities targeted at consumers and community, including social media (in alignment with activity 1.1) 4.6. Ensure proper disposal measures of antibiotics – bypharmaceutical distributors with accountability to manufacturer 4.7. Implement and monitor sale of antibiotics as per state and national guidelines – centralised database of import, distribution and sales 4.8. Conduct centralised prescription audits (State Drugs Control Department) 4.9. Monitor the quality of antimicrobials (State Drugs Control Department) 4.10. Monitor for presence of antibiotics in feeds used in veterinary sector and aquaculture 4.11. Develop and Implement drug/antibiotic take back programmes Kerala Antimicrobial Resistance Strategic Action Plan 28 Focus area: Hospitals and healthcare institutions Objective: Optimize the use of antimicrobials in hospitals and healthcare institutions 4.12. 4.13. 4.14. 4.15. 4.16. 4.17. 4.18. 4.19. 4.20. 4.21. 4.22. 4.23. Prepare institutional antibiogram for empiric use of antibiotics Formulate antibiotic policy based on institutional antibiograms and establish antimicrobial stewardship committee at all the hospitals in the state, including private sector Ensure formulary restriction (pre-authorization) and de-escalation with respect to high-end antibiotics like tigecycline, minocycline, colistin, polymyxin B & fosfomycin, etc.; carbapenems and linezolid to be included after 6 months into list of drugs requiring pre-authorization Conduct antibiotic stewardship trainingfor all doctors, MBBS students and dentists Compliance to surgical prophylaxis policyat all hospitals Train/sensitize pharmacologists in clinical pharmacology (proposal submitted to DME for establishing clinical pharmacology departments in all government medical colleges) Review legislation on electronic prescriptions, followed by training on its use, implementation and monitoring Create and usemobile apps for antimicrobial stewardship, based on institutional antibiograms Develop and share report on KARSAP implementation to state AMR committee (all members of state AMR committee, under chairmanship of ACS Health) Develop training modules for medical, pharmacy, lab technology and nursing students Conduct educational sessions for private practitioners (IMA, IAP, API, DMO) Conduct prescription audits in healthcare facilities Kerala Antimicrobial Resistance Strategic Action Plan 29 Focus area: Veterinary and aquaculture Objective: Optimize the use of antimicrobials in veterinary and aquaculture 4.24. Steps to be taken to prevent use of „antibiotics for human use‟ as „antibiotics for growth promotion in veterinary and aquaculture‟ (State Drugs Control Department, State Veterinary Council, Indian Veterinary Research Institute [IVRI], Coastal Aquaculture Authority, Fisheries Department, FSSAI) 4.25. Ban the use of colistinas a growth promotor 4.26. Adopt measures to rationalize antibiotic usage in veterinary practice, treatment and prophylaxis (Agriculture Development & Farmers' Welfare Department, Fisheries Department, Animal Husbandry Directorate,State Drugs Control Department, State Veterinary Council, IVRI) 4.27. Ban/phase off non-therapeutic use of antimicrobials for disease prevention and growth promotion in livestock and fisheries 4.28. Restrict the use of critically important antimicrobials (for humans) in food-animal farming 4.29. Develop/adopt regulations to monitor antibiotic use in animal feed/feed premix including their sale, labelling, registration, prescription and import 4.30. Develop/adopt appropriate labelling laws for feed, feed premix, antibiotics used in animals 4.31. Promote use of alternatives such as herbal drugs, animal vaccines, probiotics for use in food animals Focus area: Surveillance of antimicrobial use Objective: Establish the surveillance system for antimicrobial use at health facilities, manufacturer, distributor, seller, user and import level in humans, animals, agriculture and food sectors 4.32. Use AMC tool to measure consumption of antibiotics at health care facilities Kerala Antimicrobial Resistance Strategic Action Plan 30 4.33. Standardise tools to measure total consumption of antibiotics at the state level (in human and animal health, food and agriculture) Key stakeholders: State Drugs Control Department, Kerala State Pharmacy Council, DirectorHealth Services (DHS), DirectorMedical Education (DME), principals of medical colleges, private health sector, pharmacists‟ associations, Agriculture Development & Farmers' Welfare Department, Fisheries Department, Animal Husbandry Directorate, State Veterinary Council, Indian Veterinary Research Institute (IVRI), Coastal Aquaculture Authority, Food Safety and Standards Authority of India (FSSAI), Kerala state branch/chapter of Indian Medical Association (IMA), Indian Public Health Association (IPHA), Association of Physicians of India (API), Indian Academy of Pediatrics (IAP)… Kerala Antimicrobial Resistance Strategic Action Plan 31 Strategic priority 5 – Research and Innovations Aim: Promote research and innovations for AMR containment Focus area: Research on AMR Objective: To compile the research activities on AMR in Kerala 5.1. Conduct literature review (RGCB, KVASU, Government Medical College Kozhikode [GMCK], GMCT, Government Ayurveda College Thiruvananthapuram, Animal Husbandry Directorate, Indian System of Medicine Kerala) Timeline: 1 year Objective: To identify potential research institutes/university departments working on AMR 5.2. Compile list of institutes and relevant investigators (RGCB, KVASU, GMCK, GMCT, Government Ayurveda College Thiruvananthapuram, Animal Husbandry Directorate, Indian System of Medicine Kerala)Timeline: 1 year Objective: Define research priorities on AMR in Kerala 5.3. Define research priorities for veterinary aspects (KVASU, Animal Husbandry Directorate)Timeline: 1 year 5.4. Define research priorities for human aspects(GMCT,GMCK, RGCB)Timeline: 1 year 5.5. Define research priorities for ayurvedic aspects (Government Ayurveda College Thiruvananthapuram, Indian System of Medicine Kerala) Timeline: 1 year 5.6. Encourage research on cytokine response – resistant/susceptible bacteria (RGCB, Infectious Disease Department GMCT) Timeline: 3 years 5.7. Identify sources of AMR in hospitals, and in environment especially in water bodies, and conduct operational research on best options for containment measures/system(RGCB, Kerala State Pollution Control Board, CIFT, CSE) Kerala Antimicrobial Resistance Strategic Action Plan 32 5.8. Surveillance study on antimicrobial resistance in the community in Thiruvananthapuram and Kollam districts of Kerala (Kerala Health Services Department, State Public Health and Clinical Laboratory & RGCB) Timeline: 1 year Objective: Research for special attention on zoonotic bacteria – Campylobacter spp., EHEC, Salmonella enteritidis, S. typhimurium 5.9. 5.10. 5.11. Isolate, identify& conduct antibiogram profiling of the above organisms from animals and their products (KVASU, Animal Husbandry Directorate) Timeline: 3 years Isolate, identify & conduct antibiogram profiling and global surveillance of bacterial pathogens from humansusing whole genome sequencing–E.coli,Klebsiella sp.,Acinetobacter spp.,Pseudomonas aeruginosa,Staphylococcus aureus, Enterococcus spp. (GMCK, GMCT, RGCB) Timeline: 3 years Organise “Research Day on AMR” in institutions to showcase their research and to establish collaborations (all institutions) Focus area: Innovations Objective: Alternate strategies for combating AMR- screening of phytochemicals/herbal extracts 5.12. Herbal drug research and development(Government Ayurveda College Thiruvananthapuram, Indian System of Medicine Kerala, KVASU) Timeline: 3 years 5.13. Promote research on biofilm inhibition (RGCB, Government Ayurveda College Thiruvananthapuram, Indian System of Medicine Kerala) Timeline: 3 years 5.14. Research on development of probiotics of human origin (RGCB, Government Ayurveda College Thiruvananthapuram, Indian System of Medicine Kerala) Timeline: 3 years Kerala Antimicrobial Resistance Strategic Action Plan 33 Objective: Development of new diagnostics 5.15. Promote research for rapid bacterial diagnostic kits (RGCB, GMCT) Timeline: 3 years Objective: Innovations using information technology 5.16. Introduce information technology for tracking and analysing AMR & HAI surveillance trends for real time feedback and action (GMCT) Timeline: 3 years Key stakeholders: Rajiv Gandhi Centre for Biotechnology (RGCB), Kerala Veterinary and Animal Sciences University (KVASU), Government Medical College Thiruvananthapuram, Government Medical College Kozhikode, Central Institute of Fisheries Technology (CIFT), Government Ayurveda College Thiruvananthapuram, Indian System of Medicine Kerala, Animal Husbandry Directorate, Kerala State Pollution Control Board, CSE, Health Services Department, State Public Health and Clinical Laboratory … Kerala Antimicrobial Resistance Strategic Action Plan 34 Strategic priority 6 – Collaborations Aim: Partnership with private sector and civil society organizations for AMR containment Focus area: Public private partnership Objective:Co-opting private hospitals into the AMR programme 6.1. 6.2. Develop partnership with private hospital groups and individual hospitals on AMR & HAI surveillance, research and capacity building (IMA, Qualified Private Medical Practitioners Association, Catholic Health Association of India, Christian Medical Association of India) Timeline: 2 years Provide space for private firms in Infection Prevention Programme and AMR surveillance programme (DHS, DME, Kerala State Public Health Laboratory, Kerala Medical Services Corporation Limited) Timeline: 2 years Focus area: State disease control programmes Objective: Ensure information sharing on drug resistance in State disease control programmes 6.3. Establish regular sharing of information on AMR in State disease control programmes on TB, influenza, malaria, HIV/STI and leprosy Key stakeholders: Kerala state branch/chapter of Indian Medical Association (IMA), Qualified Private Medical Practitioners Association, Catholic Health Association of India, Christian Medical Association of India, DirectorHealth Services (DHS), DirectorMedical Education (DME), Kerala State Public Health Laboratory, Kerala Medical Services Corporation Limited, State disease control programmes on TB, Influenza, malaria, HIV, leprosy and gonococcus Monitoring and Evaluation framework Priority indicators Input (basic resources) Process (activities) Outputs (results at programme level) Outcomes (results at population level) 1. Awareness and Understanding IEC materials for relevant groups (public, farmers, professionals in health, agriculture and environment sectors) developed AMR awareness campaign organized Awareness activities for media at State, District and sub district level AMR module developed for CME/CPD for relevant professional groups Number of print articles covering AMR Inclusion of AMR in curricula of professional Universities [KUHS, KVASU] Inclusion of AMR in curricula at school and college level AMR awareness levels in target populations, e.g. % of population who know that it is inappropriate to use antibiotics for common cold or viral infections Knowledge, attitudes and practices of health workers and vets on AMR and its implications for antimicrobial use and misuse (via standard online survey) 2. Knowledge and Evidence State Coordinating Centre for AMR surveillance established with clear terms of reference Operational plan developed for AMR surveillance Number of hospitals /laboratories participating in quality assurance programme SOPs established for AMR surveillance in animals, aquaculture and environment AMR data received from all sectors Surveillance system for AMR in animals, food and environment established Report on AMR (humans, animals/food/aquaculture and environment) and AM residues in food and environment Reduced levels and trends of resistance in E. coli, Klebsiella spp., Pseudomonas aeruginosa, Acinetobacter spp., MRSA and Enterococcus spp. 3. Infection Prevention and Control State nodal institution identified for IPC % hospitals with functioning IPC committee % hospitals with adequate IPC nurses AMR issues incorporated in biosecurity guidance for farms and slaughterhouses Hib/rotavirus/typhoid, PCV vaccine coverage across the state Proportion of acute health care facilities with IPC program in place (including monitoring of hand hygiene) Number of health facilities with new or refurbished WASH facilities Number of commercial farms compliant with infection prevention guidelines and good practices Average hand hygiene compliance rates in hospitals and primary care centres. Percentage of health facilities with functional water, sanitation and hygiene under Kayakalp/SBM Number of pharmaceutical companies manufacturing antibioticshaving effluent treatment plants Priority indicators Input (basic resources) Process (activities) Outputs (results at programme level) Outcomes (results at population level) 4. Optimising Use of Antibiotics State nodal institution identified for antimicrobial stewardship Treatment guidelines reviewed and updated considering patterns of resistance and use Monitoring antimicrobial use (AMU)/consumption at facility level Legislation approved, banning sales of antibiotics incorporated in animal food Vets involved in drug control in the state Methodology developed for calculating antimicrobial use at state level Numbers of hospitals with updated AB guidelines based on local AMR pattern Percentage of tertiary care hospitals with AB stewardship programme Percentage of medical colleges/hospitals with AB stewardship programme Implementation of ban/restrictions on antibiotic premixed food in animal husbandry and aquaculture Total consumption of antibiotics monitored (state level) % of antibiotics tested by State DrugController with acceptable quality 5. Research and Innovations State AMR research agenda established Collaboration between Rajiv Gandhi Centre and stakeholders for AMR research Financing sources for KARSAP identified Monitoring indicators at state level (% major hospitals and labs reporting to government) Proportion of KARSAP activities (1) With identified funds (2) Adequately funded and implemented 6. Collaborations State AMR monitoring cell established State AMR monitoring cell functional Number of AMR projects under PPP State AMR forum established and functional Data/information from KARSAP to be reported to State and Central Government** ** Responsibility for assimilating data and reporting on M&E indicators shall sit with State AMR Coordinating Institution (GMCT); data and information will be collated and shared by GMCT with State Government and Central Government (NCDC and MoHFW).