National Action Plan on Prevention and containment of Antimicrobial Resistance 2019 - 2023

National Action Plan on Prevention and containment of Antimicrobial Resistance 2019 - 2023 امللخص التنفيذي: ، وثمة آليات لمضادات الحيوية آخذة في االرتفاع إلى مستويات خطيرة بأنحاء العالم كافةل الجراثيم إن مقاومة مقاومة جديدة آخذة في الظهور واالنتشار على مستوى العالم وهي تهدد قدرتنا على عالج األمراض املعدية الشائعة. التي أصبح عالجها -مثل االلتهاب الرئوي والسل وتسمم الدم والسيالن -ويوجد قائمة متزايدة من عدوى االلتهابات ، بسبب تدن ً .املضادات الحيوية فاعليةي أصعب، بل مستحيل أحيانا ِقّرت في الصحة العاملية نظمةملمضادات الحيوية أولوية قصوى بالنسبة إلى الجراثيم ليعّد عالج مقاومة ُ . وقد أ خطة عمل عاملية بشأن مقاومة مضادات امليكروبات، بما فيها مقاومة املضادات 5102جمعية الصحة العاملية مايو وترتكز الخطة على .ضمان الوقاية من األمراض املعدية وعالجها بأدوية مأمونة وناجعةالحيوية، وهي خطة هدفها خمس محاور اساسية: .زيادة الوعي بظاهرة مقاومة مضادات امليكروبات وفهمها .0 .تعزيز الترصد والبحث .5 .تخفيض معدالت اإلصابة بعدوى االلتهابات .3 .ألمثلاستعمال األدوية املضادة للميكروبات على الوجه ا .4 .ضمان استدامة االستثمار في مجال مكافحة مقاومة مضادات امليكروبات .2 باتباع بما فيها دولة ليبيا قطع رؤساء الدول 5102في سبتمبر ً في الجمعية العامة لألمم املتحدة بنيويورك التزاما يكروبات عبر قطاعات متعددة، نهج واسع ومنسق في معالجة األسباب الجذرية التي تقف وراء مقاومة مضادات امل منها صحة اإلنسان وصحة الحيوان والزراعة ً و ايفاءا اللتزاماتنا الدولية, وضع املركز الوطني ملكافحة .وخصوصا االمراض خطة عمل وطنية ملقاومة مضادات امليكروبات تحت مظلة مكتب منظمة الصحة العاملية بليبيا وباشراف كاديميين من مختلف القطاعات اات العالقة. حيث شددت الخطة الوطنية على اهمية لجنة واسعة من الخبراء و اال العمل بمفهوم الصحة الواحدة واهمية اشراك كافة القطاعات اات العالقة وتبنت الخطة الوطنية ملقاومة نظمة الصحة العاملية املضادات الحيوية الخطوط العريضة لالهداف االستراتيجية التي ترتكز عليها الخطة العاملية مل و تتكون الخظة الوطنية من االتي:  خطة استراتيجية توضح االهداف و االولويات.  خطة تنفيذية توضح النشاطات و الية تنفيذها و الجدول الزمني لتنفيذها و التكلفة.  خطة الرصد والتقييم تحدد مؤشرات االداء و االنجاز لكافة النشاطات. ( 5( التوعية و التثقيف. 0هدف اساس ي تتمحور حول ستة محاور مستهدفة 04الليبية على ترتكز الخطة الوطنية تعزيز السياسات والبرامج وتطبيق تدابير الوقاية ( 3تعزيز اداء املختبرات و رصد معدالت مقاومة املضادات الحيوية. ص منها كما ينبغيتنظيم وتعزيز استعمال األدوية الجيدة ( 4 .من عدوى االلتهابات ومكافحتها ّ ( 2. النوعية والتخل ( البحث العلمي. 2الهجرة الواردة و اثرها على ارتفاع معدالت مقاومة املضادات الحيوية. اهداف الخطة الوطنية: زيادة الوعي فيما يخص مقاومة الجراثيم للمضادات الحيوية في فئة العامليين في قطاع الصحة و الصحة .0 .الحيوانية .فهوم العام ملقاومة املضادات الحيوية واثرها على صحة االنسانتحسين امل .5 .تغيير السلوك العام نحو استخدام افضل للمضادات الحيوية .3 .انشاء شبكة رصد وطنية لتحديد انماط ومعدالت مقاومة املضادات الحيوية .4 ج املرض ى و توفير معلومات تعزيز اداء املختبرات الطبية لتقديم خدمات قياسية يمكن االعتماد عليها في عال .2 .صحيحة لشبكة الرصد الوطنية .تحديد االولويات املستهدفة لشبكة الرصد الوطنية .2 .تقوية برنامج مكافحة االمراض في املؤسسات الصحية .7 استحداث ممارسات لالمن البيولوجي في املراكز البيطرية و مزارع تربية الحيوانات و الصناعات الغذائية و .8 .الزراعة .زيز النظافة و الصرف الصحي السليم في املجتمعتع .9 .تعزيز النظافة و الصرف الصحي في مخيمات املهاجرين .01 .ضمان توفر دائم ملضادات حيوية اات جودة عالية .00 .ضمان االستخدام الجيد للمضادات الحيوية في االنسان .05 .ضمان االستخدام الجيد للمضادات الحيوية في الحيوان .03 .لرصد استخدام و استهالك املضادات الحيويةانشاء شبكة وطنية .04 CONTENTS Abbreviations and acronyms ................................................................................. 6 Aknowledgment ................................................................................................... 8 Introduction ........................................................................................................... 9 Frame work ........................................................................................................ 11 Country response ................................................................................................. 12 Situation analyses and assessment ..................................................................... 16 Strategic plan ...................................................................................................... 18 Operational plan and budget .............................................................................. 27 Monitoring and evaluation plan ......................................................................... 48 References .......................................................................................................... 53 Libyan national action plan on antimicrobial resistance Page 6 of 54 ABBREVIATIONS AND ACRONYMS ACC Antimicrobial resistance Coordination Committee AM Anti-Microbial AMR Antimicrobial Resistance ARI Acute Respiratory Infection ASO Antimicrobial Surveillance Office ASP Antibiotic Stewardship Programs AST Antimicrobial Susceptibility Test CRE Carbapenemase-Resistance Enterobacteriaceae DCIM Department of Compact Illegal Immigration DIC Drug information centres EMRO Eastern Mediterranean Regional office (WHO) EQA Externa Quality Assessment ESBL Extended Spectrum Beta Lactamase EU European Union FAO Food And Agriculture Organization FDCC Food and Drug Control Center GAP Global Action Plan for AMR GLASS Global Antimicrobial Resistance Surveillance System HAIs Hospital-acquired infections HCW \Health care worker INGO International Non-Governmental Organization IOM International Office of Migration IPC Infection Prevention and Control KIMADIA The State Company for Provision of Medicines and Medical Appliances M & E Monitoring and Evaluation MDR Multi Drug Resistance MoE Ministry of Education MoH Ministry of Health Libyan national action plan on antimicrobial resistance Page 7 of 54 MoI Ministry of Information MoA Ministry of Agriculture NAP National Action Plan NCAH National Centre of Animal Health NSC National Steering Committee NCDC National Center for Disease Control NCSD National Committee for Selection of Drugs NGO Non-Governmental Organisation NRL National Reference Laboratory OIE Oficina Internacional de Epizootias (world Organization of Animal Health) PHC Primary Health Care PL Peripheral Laboratory PTC Pharmacy and Therapeutics Committees SARA Service Availability and Readiness Assessment SHAMS Strengthening of Health Information and Medicine Supply Chain Management ToR Terms of Reference TWG Technical Working Groups WASH Water, sanitation and hygiene WHO World Health Organization XDR Extensively Drug Resistance Libyan national action plan on antimicrobial resistance Page 8 of 54 ACKNOWLEDGEMENT We wish to acknowledge the world health organization for providing the support and leadership in the development of this action plan. We recognize the valuable contributions of the ministry of health and national center for disease control for the development of this action plan. We offer profound thanks to world health organization representative for his assistance on achieving the goals. The action plan was made possible through collaboration of the planning committee and infection control department. Finally, we appreciate the tireless efforts of the technical working groups who gave so generously of their time and expertise. Libyan national action plan on antimicrobial resistance Page 9 of 54 INTRODUCTION Antimicrobial resistance (AMR) is a critical public health issue globally. Effective antimicrobial drugs are prerequisites for both preventive and curative measures, protecting patients from potentially fatal diseases and ensuring that complex procedures, such as surgery and chemotherapy, can be provided at low risk. Yet systematic misuse and overuse of these drugs in human medicine and food production have put every nation at risk. Resistance to antimicrobial medicines is happening in all parts of the world in a broad range of microorganisms with an increasing prevalence that threatens human and animal health. The Global Action Plan (GAP) on AMR was adopted in 2015 by all countries through decisions in the World Health Assembly, the FAO Governing Conference and the World Assembly of OIE Delegates. This followed reports of alarming rates of resistance to hospital and community-acquired infections as well as reports of resistance in agriculture, livestock and fisheries. Countries agreed to have a national action plan on AMR that is consistent with the GAP, and to implement relevant policies and plans to prevent, control and monitor AMR The Libyan national action plan has been aligned with WHO five objectives. Analysis of the current situation and addressing the gaps and the needs to reach the main goal “one health” approach involves several national sectors and actors, including human and veterinary health, agriculture and food and drug control center and environmental agencies. Therefore, a large committee of all stakeholders was formed with four technical subcommittees were established to addresses every aspect to contain antimicrobial resistance in the country. Recently, Libya has witnessed a dramatic demographic transformation caused by arrival of large numbers of immigrants that burden the healthcare sector and expected to play a major role in threatening the national and the international effort to contain the antimicrobial resistance, therefore an additional objective was proposed to evaluate the effect of the immigration on the AMR situation in Libya. A country situation analysis concluded in February 2018, focused on the concept of one health approach for strengthening systems to counter infectious diseases and related issues that threaten human, animal, and environmental health. A multidisciplinary team actively participated in this workshop, indicated that Libya is already experiencing high levels of antibiotic resistance. Furthermore, the workshop was convened to explore immediate, short Libyan national action plan on antimicrobial resistance Page 10 of 54 and long-term actions and research needs that will have the greatest effect on reducing antimicrobial resistance, while taking into account the complexities of bridging different sectors and disciplines to address this global threat. Libyan national action plan on antimicrobial resistance Page 11 of 54 OPERATIONAL FRAMEWORK To achieve optimal collaborative actions by different stakeholders in association with developing partners and international organizations aiming to strength healthcare, veterinary medicine, food safety, agriculture and research. Libyan NAP is structured around 14 main objectives covering six area of interest: (1) Awareness, education and behavioral change, (2) Surveillance and laboratories capacity , (3) Infection Prevention, hygiene and sanitation , (4) Rational use of antimicrobials, (5) AMR in Migrants and (6) Reasearch. 1. Increase national awareness of AMR among target groups within 5 years up to 85%. 2. Improve knowledge on AMR and related topics. 3. Enhance behaviour change towards better use of Antimicrobial medications (85% among healthcare workers, and 60% among public). 4. Set up a national surveillance system for antimicrobial resistance. 5. Build laboratory capacity to produce high-quality microbiological data for patient management and support surveillance activities in both human and animal sectors. 6. Identify research priorities for AMR surveillance. 7. Strengthening the IPC program in Libya. 8. Establishing bio-security (hygienic practices) in veterinary settings and animal husbandry, health food industry and agriculture. 9. Sanitation and hygiene at community level. 10. Sanitation and hygiene at migrants’ camps. 11. Ensure sustainable access to high quality antimicrobial medicines. 12. Ensure appropriate use of antimicrobial agents in human. 13. Improve and ensure appropriate use of antimicrobials in animals. 14. Establish the national surveillance system for antimicrobial use and consumption. Libyan national action plan on antimicrobial resistance Page 12 of 54 COUNTRY RESPONSE Governance A national governance mechanism is far more likely to be effective if it has political support and authority to act, if it is accountable and if it has dedicated funds and an adequate secretariat to operate. A governance mechanism is essential for coordinating national efforts to combat AMR. in order to comprise a national steering committee (NSC), which will establish supporting technical working group as needed. Terms of Reference for a National multi-sectoral steering Committee (NSC) The main purpose of the national steering committee is to oversee activities. 1. Political support: As human health is the ultimate concern of activities to control AMR, the ministry of health lead the group, but joint leadership with Ministry of Agriculture and animal worth (MoA), Ministry of Education (MoE) and ministry of Information (MoI). Libyan national action plan on antimicrobial resistance Page 13 of 54 2. Authority to act: The NSC will have sufficient authority to ensure that the ACC recommendations and plans are implemented. 3. Dedicated funds: the availability of dedicated funds will increase the operational effectiveness of the ACC. Seed funds from the government and external sources are often required initially, but government funds should be secured as early as possible to ensure political “ownership” and increase the likelihood of programme sustainability. Terms of references of AMR coordination committee (ACC) The purpose of the ACC is to oversee and, when necessary, to coordinate AMR-related activities in all sectors to ensure a systematic, comprehensive approach. Roles and Responsibility: 1. Accountability: The ACC should be lead facilitation or a senior executive function in the government and coordination of a national response to the threat of AMR. Its leadership should take the form of officially delegated authority, with more formal procedures and official monitoring, evaluation and reporting. Moreover making recommendations and progress reports and providing a platform for programme planning and implementation to NCC. 2. Secretariat: Operational sustainability is more likely when sufficient dedicated personnel and funding are available to support administrative activities. 3. Information sharing: The ACC should provide a periodic progressing report for information for mutually reinforce activities among sectors to NCDC and UN partners (WHO and IOM) which will be discussed at the regular meeting of NSC. 4. Facilitation and coordination: ACC should facilitate and, when appropriate and agreed, coordinate efforts to contain and reduce the threat of AMR at subnational, national and supranational levels. Furthermore, ACC should build a collaborative, cooperative, supportive environment for sharing knowledge, information and experience. Each participating party should understand the scope and limits of its own contributions and also its inter-dependence with other parties and with the whole system in order to meet the defined goals. The difficulty of achieving such an environment and building such a system should not be underestimated. 5. External interactions: Collaboration with internal and external agencies and organizations is essential for many countries. WHO country office can support Libya in identifying and facilitating relations with external partners. ACC will be invited, encouraged and supported to participate in any existing initiatives of the WHO country office, regional office or WHO headquarters. 6. Internal interactions: A national AMR initiative must interact with the health system and public health and disease-specific programmes and general national plan. The nature of these internal interactions and the results will depend on ACC. As many agencies and programmes have responsibilities in areas affected by AMR, a guiding principle of the ACC is to find the most appropriate ways to facilitate and provide synergy with new or existing work so that the overall objectives of the programme are achieved. Furthermore, the ACC must be appropriately integrated and have clearly defined roles and responsibilities in existing health system, public health and disease-specific programmes, animal health and production, the food sector and environmental initiatives. The cross-cutting nature of the ACC should add value to these systems and programmes, not supplant them. Membership of AMR coordination committee: The national ACC will be composed of members representing the relevant sectors, notably human health, animal health and production and the food and environment sectors, ideally, the head of the ACC will be the national AMR focal point. Libyan national action plan on antimicrobial resistance Page 14 of 54 Representatives should be given sufficient authority by their institutions to make decisions which will present periodical in NSC regular meeting. While it is important to have sufficient representation of these key stakeholders, the ACC should remain small enough to be functional, striking a balance between full representation and the functionality of the coordinating group. Meeting format and rules The meeting format and rules should conform to national norms. Standard operating procedures may be elaborated, transparently and according to the principles of best practice, to guide the activities of the coordinating committee. Members should be selected to ensure that all relevant stakeholders are equitably represented. NSC members may be invited to propose members of ACC, but the focal point and head of ACC should ensure that the proposed members have sufficient skills, knowledge, authority and influence and can collaborate. It is advisable to achieve a gender balance. ACC will form subcommittees SOCs aligned with global strategic objectives of AMR: awareness raising and behaviour changes, knowledge, surveillance, Infection Prevention and Control (IPC), hygiene and biosecurity and rational antimicrobial consumption and Use. Each committee has a clearly defined mandate and an appointed chairperson. In addition, technical working groups can be established and mandated for tasks that include providing technical input for ACC decision-making. The ACC should be supported by an appropriately resourced secretariat responsible for the logistics of meetings; minute-taking; preparation and circulation of documents (e.g. background papers, reports and advisory notes to NSC); and storage and archiving. The committee should has a mechanism (with appropriate records) to ensure that its members have no conflicts of interests and that the work of the ACC in the interests of public health is transparent. Failure to ensure these elements could undermine the credibility and limit the effectiveness of the committee. National focal point A national AMR focal point should be designated to coordinate AMR activities and tasks in the health sector. Scope, roles and responsibilities The focal point should:  Build sustained partnerships and work nationally and internationally on containment of AMR;  Identify stakeholders and facilitate formation of an inclusive NSC and ACC.  Lead and coordinate drafting of a national action plan for containment of AMR.  Facilitate and oversee implementation, M&E of the plan through the ACC.  Ensure regular data collection and information sharing by instituting effective communication and coordination among all stakeholders, the members of ACC and their constituencies, sectors and disciplines.  Coordinate national activities for establishment of AMR surveillance systems.  Report on the prevalence of and trends in AMR to the global AMR surveillance system (GLASS). Libyan national action plan on antimicrobial resistance Page 15 of 54  The focal point will be the primary contact for all issues related to AMR in the country. Technical working group ACC may decide to form a technical working group (TWG) mandated with specific tasks such as providing technical input, conducting situational analyses or drafting NAPs. Scope, roles and responsibilities The terms of reference (ToR) of the TWG shall be established by the ACC, providing specific scope, role and responsibilities. These will usually be task-specific, and focused on areas which the coordinating group have determined to be of particular focus for the country. The TWG will remain a national group and shall interact with country representatives of the required sectors, as determined by the scope of work. The TWG remains a group mandated by the ACC. As such, reporting and communications with the ACC should be regular and will be defined in the TWG ToR. Activities may include drafting technical advice and reports, contributing to country situation analyses or participating in national action plan development. Membership Depending on the purpose, scope and tasks of the TWG, membership of a TWG may come from any of the relevant technical specialities. These may include experts from areas such as infectious diseases, microbiology, infection prevention and control, social health, food and drug regulation, surveillance system expertise, environment and others. AMR Surveillance Unit (ASU): Establishing AMR surveillance unit affiliated to the IP&C administration at the NCDC to oversee the development and functioning of the national AMR surveillance system and has multidisciplinary team comprising a range of disciplines: epidemiologist, microbiologists, clinicians, data managers and the focal point for AMR surveillance and reporting to GLASS. Term of reference for the ASU: 1. Define AMR surveillance objectives within the national AMR strategy. 2. Facilitate linkages with AMR surveillance across human health, animal health and environmental sectors. 3. Develop or adapt national AMR surveillance standards, protocols and tools and coordinate their dissemination. 4. Provide guidance and information on data collection and reporting to the national reference laboratory and AMR surveillance sites. 5. Monitor and evaluate the AMR surveillance system on an ongoing basis. 6. Define strategy for participation in GLASS. 7. Assure data management structure and format and IT solutions. 8. Select and facilitate enrolment of surveillance sites. 9. Coordinate collection and compilation of national AMR data. 10. Conduct data analysis and quality assurance. 11. Analyse and feedback AMR surveillance results to AMR surveillance sites in collaboration with the national reference laboratory. 12. Aggregate and report national AMR data and data on implementation status of national AMR surveillance system to GLASS. Libyan national action plan on antimicrobial resistance Page 16 of 54 SITUATIONAL ANALYSES AND ASSESSMENT Resistance to antimicrobial drugs is a major health problem that affects the whole world. The problem is still worse in developing countries where lack of antimicrobial-resistance surveys and control policies are the norm. In Libya, misuse of antimicrobial agents by the professional and public is widespread. As in many developing countries antimicrobials can be purchased from pharmacies without prescription in Libya. Recently, a cross-sectional study was carried out in Tripoli Libya; found that the overall prevalence of ESBL producing Enterobacteriaceae was 24.5%. Klebsiella spp. (54%) and E. coli (34.4%) were the leading ESBL producers. However, these data was higher compared to previous studies carried out in Libya 10 - 20.5% [1-4]. Increased incidence of ESBL infections is also associated with an increase in MDR strains. These results was in agreement with other studies conducted in North Africa: in Algerian hospitals, ESBL existed in 16.4 31.4%; while the prevalence ranged from 11.7 to 77.8% in hospitals and was 0.7 and 7.3% in two communities in Tunisia; and ESBLs were found in 11 - 42.9% of Egyptian samples in both hospitals and communities [5]. Carbapenemase-producing Enterobacteriaceae (CRE) has been steadily spreading worldwide during the last decade. According to local study, the occurrence of CRE was 9% among Enterobacteriaceae isolates. Klebsiella spp. was the leading carbapenemase producer (44.6%) followed by A. baumannii (24%) and E. coli (11.6%), these isolates were autochthonous associated with MDR. Many studies conducted in Libya revealed the presence of carbapenem resistant-encoding genes (OXA-23, OXA-48, NDM-1, VIM-2 and GES) contributed to antibiotic resistance in Libyan hospitals [6-9]. In the Mediterranean basin, during recent years, the emergence of CRE becomes an alarming problem. The prevalence of these CRE is variable across Mediterranean countries [10]. During 2017, extremely high rates of resistance to most of the antimicrobial agents tested among carbapenem resistant Gram negative bacteria isolates, 40% of Acinetobacter spp, 32.6% of P. aeruginosa, and 12.5% of K. pneumoniae were positive for metallo β lactamases isolated in Libya [12]. There is little information on the prevalence of extensively drug resistant (XDR) pathogens in the countries of North Africa (including Libya) and the Middle East. XDR was evident among A. baumannii (61.2%); it was predominantly associated with burn patients [13]. This baseline data should engender further research to investigate the encoding genes associated with the resistant in these isolates in Libya. A study carried out on self-medication with antibiotics in the ambulatory care setting within eight countries of the Euro-Mediterranean region between 2004-2005 found that self medication in Libya was 24% and nearly 50% of interviewed Libyans indicated that they would take antibiotics for their own use without a prescription if they believe that they needed to [11]. Lack of good administration, resources, maintenance of hospitals, well trained healthcare workers, and surveillance of different diseases and support of biomedical Libyan national action plan on antimicrobial resistance Page 17 of 54 research. The poor state of health undoubtedly aggravated the problem of antimicrobial resistance in the country. Establishing monitoring systems based on routine testing of antimicrobial susceptibility and education of healthcare workers, pharmacists, and the community on the health risks associated with the problem and benefits of prudent use of antimicrobials are some of the steps that can be taken to tackle the problem in the future. Surveillance of antimicrobial consumption and use is desperately needed. Information from both surveillance programs will provide data required to direct policy on the cautious use of antimicrobials and to apprize and evaluate resistance containment interventions at local and national levels. In addition, reducing the impact of hospital-acquired infection in our hospitals is urgently required. Such action will most likely reduce antimicrobial use in the hospital setting and may lead to a reduction in high rates of antimicrobial resistance reported from hospitals in Libya. Programs dealing with control of nosocomial infections in the country should be strengthened and updated regularly. A major component of future policies for prevention and control of antimicrobial resistance in Libya should be education of healthcare workers, pharmacists, students, and the general public. There are many international agencies such as WHO, scientific societies, and other institutions that provide excellent and accurate educational resources that should be used as guidelines. In addition, local scientific and culture societies, sport clubs, mosques, schools, universities, welfare and correctional centers, and the media should be involved in educating the community about prudent use of antibiotics. The crisis of antimicrobial resistance in Libya has reached a stage that requires the ministries of health, agriculture, information education, and higher education and the research community to join forces in addressing this issue. Libyan national action plan on antimicrobial resistance Page 18 of 54 Libyan Strategic plan Develop awareness and understanding of antimicrobial resistance through effective communication, education, behaviour changes, and training Objective 1 Increase national awareness of AMR among target groups within 5 years Strategic interventions Activities 1.1. Establish evidence based public communications programme targeting audiences in human health related practices (Food chain, environment). 1.1.1. Estimate awareness and knowledge through behavioural studies about level of awareness of AMR as public health issue. 1.1.2. Organize training programs for relevant professional groups (physicians, dentists, pharmacists, nurses, Lab. Technicians) on ethics of antimicrobial prescribing, dispensing and use in addition to communication skills. 1.1.3. Establish a communication plan that includes (financial resources, human resources, training and formulation of national intersectoral coordination body. 1.1.4. Implement advocacy activity for high-level authorities to ensure implementation of AMR NAP as priority. 1.1.5. Produce audio-visual materials, training guidelines and Standard Operational Procedures (SOPs) for different activities/Procedures. 1.2. Establish evidence based public communications programme targeting audiences in animal health related practices (Food chain, environment, plant). 1.2.1. Support, train and build the capacity of the veterinarians, veterinary technicians, farmers, animal breeders on AMR including knowledge and communication skills a) Conduct a series of AMR workshops for each category b) promoting the use of healthy alternative for animal weight gross such as food supplements 1.3. Establish evidence based public communications programme targeting audience in the public (teachers, media personnel, community leaders, local non governmental organizations (NGOs), influential figures and celebrities, etc). 1.3.1. Estimate awareness and knowledge through behavioural studies in different social groups. 1.3.2. Mapping of media (TV channels, radio stations and printed materials) and the pattern of exposure and reach. 1.3.3 Organize mass public awareness campaigns using different media (traditional media, sub regional and national channels, social media) Libyan national action plan on antimicrobial resistance Page 19 of 54 1.4. Utilize the well-established public health programs e.g. vaccination program as a platform to enhance the awareness about AMR. 1.4.1. Providing the vaccination teams with AMR information to convey to parents during the vaccination activities 1.4.2. Adding basic AMR messages to the vaccination cards 1.5. Establish and implement risk communication plan to address AMR during the current emergency situation in Libya. 1.5.1. Establish donor advocacy plan with focus on AMR among Immigrants. 1.5.2. Mapping of the illegal immigrants situation in Libya and enhance the coordination with the relevant national and international organizations. 1.5.3. Implement public awareness activities among Immigrants in detention centres about AMR. 1.5.4. Enforcement of the legislation regarding the employment of the illegal immigrants. 1.5.5. conduct training and produce materials for HCWs on how to handle AMR during outbreaks. Objective 2 Improve knowledge on AMR and related topics Strategic interventions Activities 2.1. Include AMR and related topics as a core component of professional education, training, certification and development 2.2. Include AMR and related topics as a core component of the school curricula 2.1.1. Advocate for the AMR curricula among relevant decision makers (higher education) to get their approval. 2.1.2. Review, draft and produce the AMR and related topics to include them in the undergraduate curricula for human and animal health professionals, food production and agriculture. 2.1.3. Establish a training programme responsible for training modules. 2.1.4. Organize training workshops for staff on ways to introduce the new curricula both in schools and medical faculties. 2.2.1. Advocate to include AMR in the school curricula among relevant decision makers (ministry of education) to get their approval. 2.2.2. Review, draft and produce the AMR and related topics to include them in the schools curricula including visual aids and advocacy materials. 2.2.3. Train teachers, health and school social mentors where available on ways to introduce the AMR curricula. Libyan national action plan on antimicrobial resistance Page 20 of 54 Objective 3 Enhance behaviour change towards better use of antimicrobial medications ( 85% among healthcare workers, and 50% among public) Strategic interventions Activities 3.1 Establish behavioural changes program addressing the economic, social and cultural factors. 3.1.1. Analyse the current situation with regard to the pattern of AMR related behaviours and the main factors affecting those behaviours. 3.1.2. Advocate for the development and enforcement of legislations related to dispensing of antimicrobial medications (human and animal health and plants) in governmental and private sectors. 3.1.3 Advocate for the Initiation of national unified protocols for prescribing and dispensing of antimicrobial medications. 3.1.4. Organizing community outreach programs and apply cultural sensitive methods to enhance behavioural changes. Strengthen the knowledge and evidence base through surveillance and research Objective 4 Set up a national surveillance system for antimicrobial resistance Strategic interventions Activities 4.1. Establish AMR surveillance unit (ASU). 4.1.1. Write and approve terms of reference for a national coordinating centre for ASU with the mandate to oversee the AMR surveillance programme, including collecting, aggregating and sharing data. 4.1.2. Recruit office members ( e.g. epidemiologist, microbiologist, clinician and data manager) 4.1.3. Assign focal points for other sectors 4.1.4. Training of office members on the surveillance. 4.1.5. Allocate budget for the ASU office. 4.1.6. Coordinate with all stakeholders through NCDC. 4.1.7. Enrolment and data reporting to GLASS. 4.1.8. Review and modify current procurement plan to ensure sustainable provision of lab supplies. 4.1.9. Encourage collaboration with international Libyan national action plan on antimicrobial resistance Page 21 of 54 organisations. 4.1.10. Identify and update the list of notifiable diseases. 4.1.11. Identify national research priority. Objective 5 Build laboratory capacity to produce high-quality microbiological data for patient management and support surveillance activities in both human and animal sectors. Strategic interventions Activities 5.1. Designate a national reference laboratory (NRL) for AMR surveillance. 5.1.1. Write and approve terms of reference for NRL with expertise in methods for confirming and characterizing specific pathogens and organizing quality assurance schemes. 5.1.2. Assessment of the potential NRL. 5.1.3. Upgrade the capacity of NRL to fulfil approved term of references 5.1.4. Implement quality management system relevant to AMR according to the international standard. 5.1.5. Training of laboratory personnel on implementation of quality management system. 5.1.6. Harmonise the standard used for interpretation of AST across the country. 5.1.7. WHONET training 5.2. Develop national EQA to oversee the lab performance 5.2.1. Training the staff on preparation, interpretation, and quality checked of EQA panels. 5.2.2. Training on shipping standards. 5.2.3. Assessment of current specimen referral system. 5.2.4. Design an optimized specimen referral system based on the assessment. 5.2.5. Simulation exercise to test the efficiency of the developed system. 5.2.6. Develop monitoring and evaluation plan for improving the system. 5.3. Building capacity of peripheral laboratories all sectors. 5.3.1. Assessment of the potential surveillance sites. 5.3.2. Training laboratory personnel in referring adequate epidemiological data. 5.3.3. Training of laboratory technicians on approved standard investigation procedures. Libyan national action plan on antimicrobial resistance Page 22 of 54 5.3.4. Participation of EQA. 5.3.5. WHONET training. Objective 6 Identify research priorities for AMR surveillance Strategic interventions Activities 6.1. Strengths agreement with all academic and research centres in all sectors. 6.1.1. Engage relevant experts to identify current gaps in knowledge and potential research topics. 6.1.2. Collaboration to leverage available capacity to characterized genetic structure of resistant strains. 6.1.3. Encourage collaboration with international organizations. 6.1.4. Encourage the publication in international organizations. 6.1.5. Establish terms of agreements collaboration for data exchange and publication. Reduce the Incidence of Infection through Effective Sanitation, Hygiene and Infection Prevention Measures Objective 7 Strengthening the IPC program in Libya Strategic interventions Activities 7.1. Strengthening the structure of IPC program at governmental /private levels. 7.1.1. Establishing a multi-sectorial committee: the committee should include qualified /empowered /authorized members. 7.1.2. Reactivating a medical subcommittee at health care facility level. 7.1.3. Establishing IPC at level of PHC 7.1.4. Establishing IPC at level of DCIM (department of compact illegal immigration). 7.1.5. Expand vaccination coverage to include health care workers. 7.2. Creating guidelines and protocols. 7.2.1. Implementation packages Train health care workers on those implementation packages. 7.2.2. Measure compliance of health care workers/health care facilities. 7.3. Establishing sentinel nosocomial surveillance sites at different regions health. 7.3.1. Establish Building capacity of reporting/outbreaks. 7.3.2. Develop health care outbreak investigation team. Libyan national action plan on antimicrobial resistance Page 23 of 54 7.3.3. Establish a national coordination structure for surveillance of AMR. 7.3.4. Designate and develop NRL facility to coordinate effective epidemiology surveillance. 7.4. Training and Education of IPC 7.4.1. Upgrading IPC diploma. 7.4.2. Monitoring and evaluation of the current IPC diploma. 7.4.3. Create a career class for IPC professionals. 7.4.4. Establishing national training programs for health care workers on IPC principles. 7.5. Establishing a national M&E program 7.5.1. Develop monitoring tools at level of health care facilities infrastructure. 7.5.2 Develop monitoring tools at level of Health care workers on IPC practices. 7.6 Optimize physical infrastructure of health care facilities 7.6.1 Develop minimum standards for IPC in health care facilities. 7.6.2 Improve (renovate) existing buildings. 7.6.3 Enforce IPC standards in new health care facilities. Objective 8 Establishing bio-security in veterinary settings and animal husbandry, health food industry and agriculture Strategic interventions Activities 8.1 Strengthening the structure of bio-security program at governmental/private levels 8.1.1 Establishing bio-security committee at veterinary settings level and animal husbandry, health food industry and agriculture. 8.1.2 Establishing bio-security at level of Veterinary Clinics. 8.2 Create a formal organizational structure to ensure proper development and use of bio security polices and strategies. 8.2.1 Write and approve a bio-security guideline in animal health Include hygiene and bio-security and control as core content in training education of vet. Professionals. Objective 9 Sanitation and hygiene at community level Strategic interventions Activities 9.1 Promotion of personal hygiene by social mobilization and behavioral change activities. 9.1.1 Improve Access to safe and usable water. 9.1.2 Strengthening waste management system. 9.1.3 Control industrial waste. 9.1.4 Improve sanitary services. Libyan national action plan on antimicrobial resistance Page 24 of 54 9.2 Expand vaccination coverage to include adults. Objective 10 Sanitation and hygiene at migrants camps and community level Strategic interventions Activities 10.1. Promotion of personal hygiene by social mobilization of migrants at camps/community and behavioral change activities. 10.1.1. Knowledge of personal hygiene need to be verified as a base line a base line for the social mobilization campaigns. 10.1.2. Improve IPC at level of health centres at the camps. 10.1.3. Improve environmental sanitation at level of camps/community. 10.1.4. Expand vaccination programs to include all migrants at camps and community levels. 10.2. Improve environmental sanitation of water supply, and waste management (liquid and solid). 10.2.1. Improve Access to safe and usable water. 10.2.2. Strengthening waste management system. 10.2.3. Improve sanitary services. Optimize the use of Antimicrobial medicines in human and animal health Objective 11 Ensure sustainable access to high quality antimicrobial medicines Strategic interventions Activities 11.1. Strengthen the supply chain of AM (selection, procurement, storage and distribution). 11.1.1. Training programme on supply chain system. 11.1.2. Develop SOP for procurement of medicine. 11.1.3. Assess warehouses of medicine. 11.1.4. Reconstructing the warehouses to be complied with good storage and distribution practises. 11.2. Enforcement of legislation to ensure the only safe effective and regulated medicines that are available in the market. 11.2.1. Conduct orientation workshop on existing legislation targeting high level decision makers of all stakeholders. 11.2.2. Enforce regulation to minimize all substandard and falsified AMs for humans and animals. 11.3. Strengthen the national regulatory authority responsible 11.3.1. Training on pharmacovigilance /inspection and registration of medicine. Libyan national action plan on antimicrobial resistance Page 25 of 54 for registering , inspecting and monitoring use for human health. 11.3.2. Training on registration and inspection of AMs in animal health 11.4. Strengthen the national regulatory authority responsible for registering and monitoring use for animal health. Objective 12 Ensure appropriate use of AM in human Strategic interventions Activities 12.1. Improve awareness and education on rational use of AMs in healthcare facilities (Public & Private health facilities). 12.1.1. Assess AMs use in health care facilities through Questionnaire for health care providers. 12.1.2. Training workshop on rational use of AM. 12.1.3. Rational use of AM should be mandatory in CME in all health facilities. 12.2. Establishment of National standard guidelines for common infectious diseases (Public & Private health facilities). 12.2.1. Develop standard treatment guidelines for URTI and septicaemia. 12.2.2. Develop guidelines for use of AMs in surgical & dental problems. 12.3. Establish AM stewardship program in healthcare facilities. 12.3.1. Conduct meeting of expert consultation for developing framework of AM stewardship program in Libya. 12.3.2. Identify diverse pool of technical experts for collecting and collating evidence based national AMSP and develop training package. 12.3.3. Piloting AM stewardship program in three geographically selected hospitals. 12.4. Enforcement of the legislation for the AMs dispense and prescription. 12.4.1. Awareness campaign targeting dispensers, prescribers, consumers and healthcare providers on existing rules and regulation governing AM. Objective 13 Improve and ensure appropriate use of antimicrobials in animals Strategic interventions Activities 13.1. Develop legislation for the control of procurement, prescription and dispensing AMs for animal use. 13.1.1. Establish committee in MOA to review exciting legislation governing the control of procurement, prescription and dispensing AMs for animal use. 13.2. Restrict use of critically important AMs for human medicine in food production 13.2.1. Identify the list of AMs currently in use in animals. 13.2.2. Develop list to restrict AMs used for Libyan national action plan on antimicrobial resistance Page 26 of 54 animals. critical human cases. 13.3. Restrict use of AMs as growth promoters. 13.3.1 Conduct rapid assessment for the use of AMS as growth promoter. 13.3.2 Awareness campaign for the farmers. Objective 14 Establish the national surveillance system for antimicrobial use & consumption Strategic interventions Activities 14.1. Establish a surveillance system to monitor and assess antimicrobial consumption in human. 14.1.1. Develop methodology to estimate AMs consumption in human health through expert consultation. Libyan national action plan on antimicrobial resistance Page 27 of 54 Operational plan and budget Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic intervention 1.1. Prepare an evidence-based public communication programme for people in human health practice. Activity 1.1.1. Estimate awareness and knowledge through behavioural studies about level of awareness of AMR as public health issue among human and animal health care workers. Sub-activity 1.1.1.1 Measure AMR awareness among the human healthcare workers. Awareness survey 1 2019 Nationwide Research department in MoH And research department of NCDC + ACC 20.000 NA Results of the two studies availability Sub-activity 1.1.1.2 Measure AMR awareness among the animal healthcare workers. Awareness survey 1 2019 Nationwide MoA + ACC د االرشا مركز الزراعي مركز االرشاد بيطريال 20.000 NA Results of the two studies availability Activity 1.1.2. Establish a communication plan that includes (financial resources, human resources, training and formulation of national intersectoral coordination body) Sub-activity 1.1.2.1 Conducting an advocacy workshop for concerned ministers on AMR plan. workshop 1 2019 ACC + WHO expertise 10.000 Libyan national action plan on antimicrobial resistance Page 28 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 1.1.2.2 Assign a team of expertise to draw the outline of the frame for the plan. plan Q2 2019 NCDC + MoH ACC (including media representative of each ministries) 5.000 Plan drafted Sub-activity 1.1.2.3 Submitting the plan for revision and approval by stakeholders and high authority. Q3 2019 ACC Plan approved Activity 1.1.3. Organize training programs for different relevant professional groups (Physicians, Dentists, Veterinarians, Pharmacists, Nurses, and Lab. Technicians) on antimicrobial ethics in prescribing, dispensing and use. Sub-activity 1.1.3.1 Create guidelines and training modules covering AMR knowledge and communication skills. 1 2019 ACC 10.000 Sub-activity 1.1.3.2 Conducting a workshop for different professions related to AMR (Physicians, Dentists, Veterinarians, Pharmacists, Nurses, and Lab. Technicians). workshop 6 2019 Medical Manpower Development Center + WHO 30.000 Libyan national action plan on antimicrobial resistance Page 29 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 1.1.3.3 Conducting a series of cascade training workshops for different professions related to AMR (Physicians, Dentists, Veterinarians, Pharmacists, Nurses, and Lab. Technicians). workshops 6 2019-2020 Medical Manpower Development Center + WHO 30.000 Strategic intervention 1.3. : Establish evidence based public communications programme targeting audience in the public (teachers, media personnel, community leaders, local non-governmental organizations (NGOs), influential figures and celebrities, etc). Activity 1.3.3. Organize mass public awareness campaigns using different media ( traditional media, Social media) Sub-activity 1.3.3.1 Drafting key messages on AMR best-use practices. 2019 local ACC and concerned stakeholders 5.000 Approved messages Sub-activity 1.3.3.2 Production of audio-visual and other materials 2019 Nationwide ACC and concerned stakeholders 50.000 No. of media products Sub-activity 1.3.3.3 Selection of the channels / primetime for broadcasting including trusted social media accounts. 2019 Nationwide ACC and concerned stakeholders Media offices in NCDC & MoH Libyan national action plan on antimicrobial resistance Page 30 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 1.3.3.4 Making use of the relevant global events like WAAW and hand hygiene day to disseminate and broadcast the materials of the campaign. Awareness campaign 1 Relevant dates Nationwide ACC and concerned stakeholders 150.000 No. of participating sectors Sub-activity 1.3.3.5 Reaching out to the immigrants in camps and detention centres with awareness messages on AMR in their own languages. Awareness campaign 1 Nationwide ACC and concerned stakeholders including INGOs Included in the above sub-activity No. of camps covered Strategic intervention 2.1. Include AMR and related topics as a core component of professional education, training, certification and development. Activity 2.1.1. Include AMR and related topics in undergraduate curricula for human health professionals, animal health professionals and agriculture professionals Sub-activity 2.1.1.1. Advocate for the AMR curricula among relevant decision makers (Education and Higher Education) to get their approval. Advocate meeting 1 2020 ACC with MoE 10.000 A decision is taken to include AMR in the curricula Sub-activity 2.1.1.2. Revising existing undergraduate curriculum for human health professionals, animal health professionals and agriculture professionals to incorporate AMR and Expert workshop … 2020 … ACC with MoE experts from different fields 20.000 … Revised curriculum introduced Libyan national action plan on antimicrobial resistance Page 31 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator related issues and drafting new undergraduate curriculum Sub-activity 2.1.1.3. Submitting the new undergraduate curriculum 2020 ACC with MoE and experts from different fields AMR content included in the Curricula Strategic intervention 2.2. Include AMR and related topics as a core component of school curricula. Activity 2.2.1. Include AMR and related topics in schools teaching programmes Sub-activity 2.2.1.1. Advocate for the AMR in school teaching programmes among relevant decision makers (ministry of Education) to get their approval. Advocate meeting ACC with MoE and experts from different fields 10.000 A decision is taken to include AMR in the school teaching programmes Sub-activity 2.2.2.1. Review, draft and produce AMR related content ACC with MoE and experts from different fields 5.000 AMR content included in the teaching programme Sub-activity 2.2.3.1. Train teachers, health and school social mentors where available on ways to introduce the AMR curricula Training course 10 ACC with MoE and experts from different fields 50.000 Human resources are well trained on introducing Libyan national action plan on antimicrobial resistance Page 32 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator AMR teaching programme Strategic intervention 3.1. Establish behavioural changes program addressing the economic, social and cultural factors. Activity 3.1.1. Analyse the current situation with regard to the pattern of AMR related behaviours and the main factors affecting those behaviours. Sub-activity 3.1.1.1. Conduct baseline assessment study on patterns of AMR related behaviours survey 1 2019 Nationwide ACC with MoE and experts from different fields 15.000 A baseline study is conducted Activity 3.1.2. Advocate for the development and enforcement of legislations related to dispensing of antimicrobial medications (human & animal health and plants) in governmental and private sectors. Sub-activity 3.1.1.2. Review of current laws related to AMR Expert meeting 2019 ACC with MoH and concerned entities 5.000 Health related laws are revised Sub-activity 3.1.1.3 Conducting advocacy meeting with the decision makers and introducing the suggested revised or developed legislations 2019 ACC with ministry of health, parliamentaria ns and concerned bodies 10.000 Advocacy meeting conducted Libyan national action plan on antimicrobial resistance Page 33 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic intervention 4.1. Establish AMR surveillance unit (ASU). Activity 4.1.1. Write and approve terms of reference for a ASU with the mandate to oversee the AMR surveillance programme, including collecting, aggregating and sharing data. Sub activity 4.1.1.1. Revise and approve TOR 1 1 Q1 2019 NCDC NCDC - NCDC Decree approved Activity 4.1.2. Recruit office members ( e.g. epidemiologist, microbiologist, clinician and data manager) Sub-activity 4.1.2.1. Write & approve job description for each member NA 8 Q2 2019 NCDC NCDC - NCDC Approved Sub-activity 4.1.2.2 Appoint office members NA 8 Q4 2019 NCDC NCDC - NCDC ASU appointed Activity 4.1.4. Training of office members on the surveillance. Sub-activity 4.1.4.1 Develop & approve surveillance protocols and training plan 2019 Local & abroad NCDC 15.000 NCDC or international organization Develop & approved Sub-activity 4.1.4.2 Implementation of training plan Training course 2019 Local & abroad NCDC 15.000 NCDC or international organization Office members trained Libyan national action plan on antimicrobial resistance Page 34 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Activity 4.1.7. Enrolment in GLASS. Sub-activity 4.1.7.1 Enrolment in GLASS Q1 2018 Local & abroad ASU Free achieved Strategic interventions 5.1. Upgrade a national reference laboratory for AMR surveillance. Activity 5.1.2. Assessment of the potential NRL. Sub-activity 5.1.2.1 Write and approve terms of reference for a NRL 2019 NCDC NCDC - - TOR develop Sub-activity 5.1.2.2 Assessment of the potential NRL 2019 NCDC National or international assessor (WHO) Assessment report Sub-activity 5.1.2.3 Developing a plan for improvement & upgrading based on assessment Expert meeting 2019 NCDC ASU 5.000 … Plan develop & submitted Sub-activity 5.1.2.4 Implementation of the plan Q4 2020 NRL ASU&NRL 100.000 NCDC Implementati on of the plan Libyan national action plan on antimicrobial resistance Page 35 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic interventions 5.3. a. Building capacity of peripheral laboratories (PL). Activity 5.3.1. Assessment of the potential surveillance sites Sub-activity 5.3.1.1 Write & approve terms of reference for surveillance sites 2019 NCDC NCDC - - ToR develop Sub-activity 5.3.1.2 Assessment & selection of the potential surveillance sites 2019 National international assessor(WHO) 5.000 Assessment report and selected sites Sub-activity 5.3.1.3 Developing a plan for improvement & upgrading based on assessment 2019 NCDC ASU … Plan develop & submitted Sub-activity 5.3.1.4 Implementation of the plan Q1 2020 Participati ng lab ASU & NRL NCDC Implementati on of the plan Strategic intervention 5.3.b. Assessment of reference and non- human laboratories Activity 5.3.1. Assessment of the potential reference and surveillance sites Sub-activity 5.3.1.1 Assessment of the potential surveillance sites& identifying the gaps 2019 National or international assessor Assessment report Libyan national action plan on antimicrobial resistance Page 36 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic intervention 7.1: Strengthening the structure of IPC program at governmental/private levels Activity 7.1 Strengthening the structure of IPC program at governmental/private levels Sub-activity 7.1.1 Establishing a technical working group (multi sectorial). 1 Q2 2019 Nationwide MoH TWG established Sub-activity 7.1.2 Establishing a medical sub committee at health care facility level. Q2 2019 Director of the health facility No. of sub committee established Sub-activity 7.1.3. Expand vaccination coverage to include health care workers 2019 MoH Strategic intervention 7.2 : Creating guidelines and protocols Activity 7.2. Creating guidelines and protocols Sub-activity 7.2.1. Develop guidelines and protocols. Expert meeting 2019 Technical committee/ MoH 30.000 Guidelines developed Sub-activity 7.2.2. TOT Training course for health care workers on guidelines and protocol Training course 1 2020 MoH 30.000 Sub-activity 7.2.3. cascade Training courses for health care workers on guidelines and protocol Training courses 6 2020-2023 Nationwide 30.000 No. of HCW trained Libyan national action plan on antimicrobial resistance Page 37 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 7.2.4. Measure compliance of health care workers/health care facilities Implementa tion research 1 2022 Nationwide MoH 40.000 Study results obtained Strategic intervention 7.3. Establishing sentinel nosocomial surveillance sites at different health facilities at different regions Activity 7.3. Establishing Sentinel Nosocomial Surveillance sites at Different health facilities at different regions Sub-activity 7.3.1. Develop / update and distribution of nosocomial surveillance manuals Expert meeting Q2 2019 Nationwide NCDC/MoH and hospitals 40.000 Sub-activity 7.3.2. Build the capacity on reporting of nosocomial infection workshops 20 Q1 2019 NCDC/MoH and hospitals 60.000 Sub-activity 73.3. Develop and update NRL facility to coordinate an effective epidemiological surveillances 1 2019-2020 NCDC/MoH and hospitals 40.000 Strategic intervention 7.4. Training and education of IPC Activity 7.4. Training and Education of IPC Sub-activity 7.4.1. Upgrading IPC diploma 2019-2020 NCDC/ MoH Sub-activity 7.4.2. Create a career class for IPC professionals 2019 MoH Libyan national action plan on antimicrobial resistance Page 38 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 7.4.3. Establishing a national training programs for health care workers on IPC principles Training course 3/ year 2019-2023 Nationwide MoH 100.000 No. of trained HCW Strategic intervention 7..5. Optimize physical infrastructure of health care facilities Strategic intervention 7.5. Optimize physical infrastructure of health care facilities Sub-activity 7.5.1. Develop minimum standards for IPC in health care facilities and assessment of existing HCF 1 2019-2022 Nationwide MoH No of HCF assessed Sub-activity 7.5.2. Improve (renovate) existing buildings 2019-2022 MoH Sub-activity 7. 5.3. Enforce IPC standards in new health care facilities 2019-2022 MoH Strategic intervention 7.6. Establishing a National M&E Program Strategic intervention 7.6. Establishing a National M&E Program Sub-activity 7.6.1. Develop monitoring tools at level of health care facilities infrastructure. 1 2019-2020 MoH 5.000 Libyan national action plan on antimicrobial resistance Page 39 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 7.6.2. Develop monitoring tools at level of Health care workers on IPC practices 1 2019-2020 MoH 5.000 … Strategic Interventions 8.1. Strengthening the structure of ICP (bio-security) program at Governmental/Private levels Activity 8.1. Strengthening the structure of ICP (bio-security) program at Governmental/Private levels Sub-activity 8.1.1 Establishing bio-security committee at veterinary settings level and animal husbandry, health food industry and agriculture. 2019 MoA and FDCC Sub-activity 8.1.2 Establishing bio-security program at level of veterinary clinics Expert meeting 2020 MoA 15.000 Program established and No. of vet. Clinic involved Strategic Intervention 8.2. Create a formal organizational structure to ensure proper development and use of bio-security polices and strategies Activity 8.2. Create a formal organizational structure to ensure proper development and use of bio-security polices and strategies Sub-activity 8.2.1. Write and approve guideline in animal health Include hygiene and bio-security and control as core content in training education of veterinary professionals Expert meeting 2020 MoA 15.000 Libyan national action plan on antimicrobial resistance Page 40 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 8.2.2. Conduct a TOT training courses on IC (bio-security) Training course 1 2020-2022 Nationwide MoA 30.000 Sub-activity 8.2.3. Conduct a series of cascade training courses on IC (bio security) Training course 10 2020-2022 Nationwide MoA 50.000 No. of professionals trained Strategic Interventions 9.1. Promotion of personal hygiene by social mobilization and behavioral change activities. Activity 9.1. Promotion of personal hygiene by social mobilization and behavioral change activities. Sub-activity 9.1.1. Knowledge of personal hygiene need to be verified as a base line for the social mobilization campaigns. Survey 1 2019-2020 Nationwide NCDC/ MoH 15.000 Results obtained Sub-activity 9.1.1. Improve WASH services 2019-2024 Ministry of housing and utilities Water and sanitation company Sub-activity 3.2.2. Strengthening waste management system including medical waste 2019-2024 … Ministry of housing and utilities 150.000 Libyan national action plan on antimicrobial resistance Page 41 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic intervention 9.2. Expand vaccination coverage to include adults and healthcare workers Activity 9.2. Expand vaccination coverage to include adults. Sub-activity 9.2.1 Awareness campaigns to include adult vulnerable groups within national vaccination programs Awareness campaign 1 2019-2020 Nationwide MoH 15.000 Awareness increased and No. of adult vaccinated Strategic Interventions 10.1: Promotion of personal hygiene by social mobilization and behavioural change activities of migrants at camps/community Activity 10.1: Promotion of personal hygiene by social mobilization and behavioural change activities of migrants at camps/community Sub-activity 10.1.1 Knowledge of personal hygiene need to be assessed as a base line for the social mobilization campaigns Survey 1 2019-2022 Nationwide MoH and all partners working with immigration 15.000 Results of the survey obtained Sub-activity 10.1.2 Improve IPC program at level of health centres at the camps Training course DCIM , INGOs, NGOs , UN agencies 10.000 No. of camps covered Sub-activity 10.1.3 Improve environmental sanitation at level of camps DCIM , INGOs, NGOs , UN agencies (OIM) Sub-activity 10.1.4 Expand vaccination programs to include all migrants at camps and community levels. MoH UN agencies, NGOs, DCIM, INGOs Libyan national action plan on antimicrobial resistance Page 42 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic Interventions 10.2. Improve environmental sanitation of water supply, and waste management (liquid and solid) at level of migrant camps. Activity 10.2. Improve environmental sanitation of water supply, and waste management (liquid and solid) at level of migrants’ camps. Activity 10.2.1 Improve WASH services General water authority , UN agencies (IOM) Activity 10.2.2 Strengthening waste management system. 2022 General services company UN agencies (IOM) Strategic activity 11.1. Strengthen the supply chain of AM (selection, procurement, storage and distribution) Activity 11.1. Strengthen the supply chain of AM (selection, procurement, storage and distribution) Sub-activity 11.1.1. Training programme on supply chain Management Focusing on AMs Training course 1 Q3 2019 Nationwide MOH, MSO in coordination with SHAMS project 10.000 Number of participant trained Sub-activity 11.1.2. Develop SOP for procurement of medicine Expert meeting Q3 2019 MoH, MSO in coordination with SHAMS project 5.000 SOP developed and endorsed Sub-activity 11.1.3. Assess MSO warehouses 1 2019 Nationwide MoH, MSO 5.000 Comprehensive assessment of all warehouses conducted Libyan national action plan on antimicrobial resistance Page 43 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 11.1.4 Reconstructing the warehouses to be complied with good storage and distribution practises MoH, MSO warehouses up to the international standard Strategic activity 11.2. Enforcement of legislation to ensure the only safe effective and regulated medicines that are available in the market Activity 11.2. Enforcement of legislation to ensure the only safe effective and regulated medicines that are available in the market Sub-activity 11.2.1 Conduct orientation workshop on existing legislation targeting high level decision makers of all stakeholders workshop 1 Q3 2019 Pharmacy administration/ MoH 10.000 Number of decision maker attended on legislation Sub-activity 11.2.2. Enforce regulation to minimize all substandard and falsified AMs for humans and animals Q4 2019 Pharmacy administration. Inspection and monitoring directorate % of non released AMs FDCC report Strategic activity 11.3. Strength the national regulatory authority responsible for registering, inspecting and monitoring use for human health Activity 11.3. Strength the national regulatory authority responsible for registering, inspecting and monitoring use for human health Sub-activity 11.3.1. Training on pharmaco vigilance /inspection and registration of medicine Training course 1 2020 Pharmacovigila nce committee/ NCDC . FDCC. MoH 15.000 Number of participant trained Libyan national action plan on antimicrobial resistance Page 44 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Sub-activity 11.3.2 Training on registration and inspection of AMs in animal health Training course 1 2020 MoA/MoH 15.000 Number of participant trained Strategic intervention 12.1. Improve awareness and education on rational use of AMs in healthcare facilities (public and private health facilities) Activity 12.1. Improve awareness and education on rational use of AMs in healthcare facilities (public and private health facilities) Sub-activity 12.1.1. Assess AMs use in health care facilities (public & private health facilities) through questionnaire for health care providers. Survey 1 Q4 2019 Nationwide MoH Infection control administration at NCDC 20.000 Report on the result of Questionnaire Sub-activity 12.1.2 training workshop on rational use of AM(public & private health facilities) 6 2020-2022 Nationwide IPC department at NCDC 60.000 Number of participant Sub-activity 12.1.3 integrate rational use of AMs in CME in all health facilities (public & private health facilities) 2021 Hospitals and primary health care administration Number of health care facilities adapted rational use of AMs in their CME programs Libyan national action plan on antimicrobial resistance Page 45 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic intervention 12.2. Establishment of national standard guidelines for common infectious diseases (public and private health facilities) Activity 12.2. Establishment of national standard guidelines for common infectious diseases (public and private health facilities) Sub-activity 2.2.1 Develop standard treatment guidelines for use of AMs in URTI, septicaemia, surgical & dental problems. Expert meetings Q4 2019 MoH, Scientific committees 35.000 STGs published and disseminated in hospitals and private sector Strategic intervention 12.3. Establish AM stewardship program in healthcare facilities Activity 12.3. Establish AM stewardship program in healthcare facilities Sub-activity 2.3.1. Conduct expert consultation meeting for developing framework of AM stewardship program in Libya Q4 2019 MoH, NCDC 20.000 AM stewardship expert meeting is conducted Sub-activity 12.3.2. Identify diverse pool of technical experts for collecting and collating evidence based national AM stewardship program and develop training package. 2020 MoH, NCDC List of technical experts Sub-activity 12.3.3. Piloting AM stewardship program in 1 main hospitals 2020 30.000 APS implemented in 1 main hospitals Libyan national action plan on antimicrobial resistance Page 46 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Strategic intervention 12.4. Enforcement of the legislation for the AMs dispense and prescription Activity 12.4. Enforcement of the legislation for the AMs dispense and prescription Sub-activity 12.4.1. Awareness campaign targeting dispensers, prescribers, consumers and healthcare providers on existing rules and regulation governing AMs 1 2019 Nationwide Pharmaceutical Admin. /NCDC 60.000 Number of dispensers, prescribers, consumers and healthcare providers reached with the campaign Strategic intervention 13.1. Improve and ensure appropriate use of antimicrobials in animals Activity 13.1. Develop legislation for the control of procurement, prescription and dispensing AMs for animal use Sub-activity 3.1.1. Establish committee in MoA to review existing legislation governing the control of procurement, prescription and dispensing AMs for animal use 2020 MoA 5.000 Committee established, legislation reviewed, report produced and disseminated Activity 13.2. Restrict use of critically important AMs for human medicine in food production animal Sub-activity 3.2.1. Identify the list of AMs currently in use in animals 2020 MoA List produced and validated Sub-activity 3.2.2. Develop list to restrict AMs used for critical human cases 2020 MoA / MoH List produced, endorsed and disseminated Libyan national action plan on antimicrobial resistance Page 47 of 54 Sub-activity Unit Quantity Date Location Responsible entity Cost (LD) Source of funding Indicator Activity 13.3. Restrict use of AMs as growth promoters Sub-activity 3.3.1. Conduct rapid assessment for the use of AMs as growth promoter survey 1 2020 MoA / FDCC 15.000 Assessment report produced Sub-activity 3.3.2. Awareness campaign for the farmers 1 2021 Nationwide MoA 60.000 % of Farmers covered by the campaign Strategic intervention 14.1. establish the national surveillance system for antimicrobial use and consumption Activity 14.1. Establish a surveillance system to monitor and assess antimicrobial consumption in human Activity 14.1.1. Develop or adopt methodology to estimate AMs consumption in human health through expert consultation 2019 PA/MoH health information centre 5.000 Methodology formulated and approved. Activity 14.1.1. Training on estimating AMs consumption in human health Training course 1 2020 abroad WHO 30.000 Estimation of consumption started Libyan national action plan on antimicrobial resistance Page 48 of 54 Monitoring and evaluation plan Planning element (activity linked to the strategic plan) Indicator Type and purpose Value (calculation) Frequency of data collection Data source Method Baseline 1.1. Increase national awareness of AMR among target groups within 5 years up to 85%. Level of awareness by all target groups Assessment of the impact on all target groups Percentage of increase in the level of awareness among all target groups. Two; Baseline and final survey assessment Baseline survey report, post intervention survey reports Awareness survey Measured in baseline survey 2.1. Include AMR and related topics as a core component of professional education, training, certification and development. Revised curricula available for target professional groups M&E of outcome Yes/No No. of curricula /No. of professional groups to target Annually MoE Field visit Regular documentation system Quality assurance offices AMR related curricula available only in some medical and para medical schools 3.1. Establish behavioural changes program addressing the economic, social and cultural factors in respect to current situation. The economic, cultural, social factors affecting the AMR related practices are addressed strategically M&E of outcome Yes/No Annually ACC AMR surveillance programme implémentation report No behaviour change programme is available 1.3.3.5. Reaching out to the immigrants in camps and detention centres with awareness messages on Improvement in the level of AMR awareness among immigrants Activity Yes/No Percentage of coverage Biannually ACC in collaboration with relevant national Field visit and Survey No baseline study is available Libyan national action plan on antimicrobial resistance Page 49 of 54 Planning element (activity linked to the strategic plan) Indicator Type and purpose Value (calculation) Frequency of data collection Data source Method Baseline AMR in their own languages. agencies and international NGOs 3.1.1. Analyse the current situation with regard to the pattern of AMR related behaviours and the main factors affecting those behaviours. A study revealed the patterns, causes and factors related to AMR and reflected the effect of current situation. M&E of activity Yes/No Once ACC in collaboration with relevant national agencies In-depth interviews and survey No baseline data 4.1. ASU functioning and delivering data Reporting data to GLASS Output Yes/ No Annually ASU GLASS platform NA 5.1. & 5.3 NRL and Surveillance peripheral lab. Produce high quality microbiological data for patient Output Number of labs involved Annually ASU EQA NA 3.3b. Assessment of reference and peripheral laboratories non-human sectors Assessment report Process Yes/ No Once ASU Report NA 5.3.1.4. Implement improvement plan of non human labs Data delivered from non-human labs Output Number of Labs Annually ASU Report NA 5.1. Identify research priorities for AMR surveillance List of AMR priority pathogens Output Yes/No Annually ASU Data report and Experts advice NA 6.1 Develop national EQA to oversee the lab performance Functional EQA system Output Yes/No Annually NRL report from NRL NA Libyan national action plan on antimicrobial resistance Page 50 of 54 Planning element (activity linked to the strategic plan) Indicator Type and purpose Value (calculation) Frequency of data collection Data source Method Baseline 6.1. Evaluate the effect of immigrant on AMR situations Evaluate AMR in areas heavily populated by immigrants Process Proportion Annually NRL Research study NA 7.1. Strengthening the IPC program (objective) Proportion of secondary health care facilities applying IPC measures Output Proportion Biannual Hospital reports and assessment visits Data analysis NA 7.1. Training and Education on IPC Improved KAP among Healthcare workers (HCWs) Output Score Every 2 years IPC directorate/ NCDC Knowledge attitude and practice (KAP) studies report N/A 7.2. Develop guidelines and protocols (Intervention) IPC guidelines and protocols are developed and updated Input Yes/No Updating every 4 years NCDC and MoH Review of guidelines documents NA 7.3. Establishing Sentinel Nosocomial Surveillance sites at different health facilities at different regions Proportion of sentinel sites that perform nosocomial surveillance according to national standards Output Proportion Annually MoH Surveillance report + assessment NA 8.1. Strengthening the structure of IPC program at governmental/private levels (intervention) Committee developed & membership updated Input yes/No Reviewed every 4 years MoH MoH documents N/A Libyan national action plan on antimicrobial resistance Page 51 of 54 Planning element (activity linked to the strategic plan) Indicator Type and purpose Value (calculation) Frequency of data collection Data source Method Baseline 8.1. Enhance bio-security and hygienic practices in veterinary settings and animal husbandry, health food industry and agriculture Create and revise curricula for target vet & related food industry groups Output Yes/No Annually Key information at MoA Key informant interview N/A 8.2.1. Write and approve a bio-security guideline in animal health, health food industry and agriculture. Include hygiene and bio security and control as core content in training education of vet. Professionals guidelines and protocols are developed Input Yes/No Every 4 years NCAH /ministry of agriculture and FDCC Review NCAH documents N/A 9.1. Promotion of personal hygiene by social mobilization and behavioral change activities Improved KAP among population Impact KAP Score Every 4 years MoH, NCDC, IPC technical committee KAP study NA 10.1. Improve environmental sanitation of water supply, and waste management Percentage of population using a basic drinking water service in migrants camps Outcome Proportion Annual DCIM, INGOs, NGOs, UN agencies (OIM), Water and Sanitation Company Survey study N/A 11.1.4 Reconstructing the warehouses to be complied with good storage and distribution practises 2 warehouses fully constructed and functioned according to the Output Proportional Once MoH Auditing 1 Libyan national action plan on antimicrobial resistance Page 52 of 54 Planning element (activity linked to the strategic plan) Indicator Type and purpose Value (calculation) Frequency of data collection Data source Method Baseline international standard 12.2.1 Develop standard treatment guidelines for URTI ,septicaemia, surgicl & dental Ams use STGs published and disseminated in hospitals Input Yes/ no Once MoH Guidelines N/A 12.3.3 Piloting AM stewardship programme in 3 main hospital AMS programme implemented in 3 hospitals Output proportional Annually MoH Auditing N/A 13.2.2 Develop list to restrict AMS used for critical human cases in animal use List produced, endorsed and disseminated Output Yes/ No Once MoA/ FDCC Formal list N/A 14.1.1 Develop methodology to estimate AMs consumption in human health through expert consultation Methodology formulated and approved. 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