National Action Plan on Antimicrobial Resistance (NAP AMR) 2024-2029

Ministry of Health Republic of Maldives National Action Plan on Antimicrobial Resistance (NAP AMR) 2024-2029 Endorsement Number Plan/23MOH/2024/22 Endorsed by: Aishath Samiya, Permanant Secrerary 1st December 2024 Signature: Verified for endorsment: Aminath Shaina Abdulla, Deputy Director General Policy Implementa�on and Interna�onal rela�ons Division 1st December 2024 Signature: Ministry of Health Republic of Maldives All rights reserved. No part of this publica�on may be reproduced, stored in a retrieval system or transmi�ed in any means, electronic, mechanical, photocopying, recording or otherwise without wri�en permission of Ministry of Health, Republic of Maldives. Short excerpts from the publica�on may be reproduced in respect to any fair dealings for the purpose of research or review, provided due acknowledgement is made. II Table of content National Action Plan on Antimicrobial Resistance (NAP AMR) Table of content Foreword by Minister of Health Foreword by WHO Representative Acknowledgment Executive summary Abbreviations and Acronyms Background Introduction Situation locally Rationale of the action Plan Scope Guiding principles Objectives Objective 1: Establish governance structure for AMR Annexure Annex 1. SWOT analysis on AMR program implementation Annex 2. Situation analysis of NAPAMR 2017 to 2022 implementation Annex 3. Tripartite AMR Country Self-Assessment Survey 2022 Maldives (TrACSS)-AMR governance component Annex 4. Facility level data collection tool for IPC and Antimicrobial Stewardship program (AMSP) References I III IV V VI VII VIII 1 1 5 14 14 14 15 15 52 52 56 63 63 76 III Foreword by Minister of Health Antimicrobials are crucial to modern medicine for treating infections and supporting a range of medical procedures. However, misuse across human, animal, and agricultural sectors has led to rapid rise of “superbugs”—resistant pathogens that are no longer treatable with current medicines. In 2019 alone, these infections led to over 1.27 million deaths globally. Rapid spread of antimicrobial resistance (AMR), combined with a lack of new treatments, has posed AMR serious global health threat. Recognizing this urgency, the Maldives adopted the World Health Organization's Global Action Plan (GAP) on AMR in 2015, becoming a regional leader in AMR containment efforts. The establishment of the National Multisectoral Coordination Committee in 2016 marked a crucial step, initiating our first National Action Plan (NAP) on AMR (2017–2022), which was aligned with GAP's strategic objectives. Despite challenges posed by the COVID-19 pandemic, the Maldives achieved significant progress under the first NAP, driven by the commitment of five technical committees focused on specific To build on these achievements, a comprehensive review of the NAP was conducted in 2023, involving extensive stakeholder consultations and a second situation analysis to identify critical gaps and shape our next strategy. This led to the development of the second National Action Plan on AMR (2024–2029), which incorporates two new focus areas: strengthening governance structures and enhancing regulatory frameworks. These additions aim to establish a more resilient, sustainable approach, equipping the Maldives to manage AMR effectively and contribute to global containment efforts. The importance of national AMR strategies was emphasized again on September 26, 2024, at the 79th United Nations General Assembly, where renewed commitments called for a strengthened global response to AMR through a One Health approach. As we embark on implementing the second National Action Plan on AMR (2024–2029), the Maldives reaffirms its dedication to addressing this urgent threat. Having endorsed the first National Action Plan, I am honoured to support this second plan, which builds on past lessons and renews our commitment to combating AMR. I encourage all stakeholders to join in promoting the responsible use of antimicrobials, helping to preserve these essential medicines for future generations. Abdulla Nazim Minister of Health goals aligned with international standards. IV Foreword WHO Representa�ve 'Antimicrobial Resistance' (AMR) occurs when bacteria, viruses, fungi, and parasites change over time and no longer respond to medicines. This makes infections harder to treat and increases the risk of disease spread, severe illness and death. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or even impossible to treat. As a result, Antimicrobial Resistance has become a huge threat to global health security, healthcare, global trade, agriculture, and the New global estimates show that in 2019, nearly 5 million human deaths worldwide were associated with bacterial Antimicrobial Resistance, of which 1.3 million human deaths were directly attributable to bacterial Antimicrobial Resistance. In a high-impact scenario, Antimicrobial Resistance will reduce global annual GDP by 3.8% by 2050. If left unchecked, in the next decade, it could result in a GDP shortfall of US$ 3.4 trillion annually, pushing 24 million more people into extreme poverty. The consequences of Antimicrobial Resistance threaten the attainment of the Sustainable Development Goals which were recently agreed upon by UN member states. Since 2014, preventing and combating Antimicrobial Resistance has been one of eight Flagship Priorities of the WHO South-East Asia Region, which is at high risk for the emergence and spread of Antimicrobial Resistance. With WHO's support, Maldives had developed its first National Action Plan to address Antimicrobial Resistance in 2016 and has continued to implement this action plan between years 2017-2022. Multisectoral working groups and coordination committees on Antimicrobial Resistance have been established at country level, in alignment To further assess the content and determine alignment with the Global Action on Antimicrobial Resistance, WHO is pleased to have supported the review and updating of existing Maldives National Action Plan on Antimicrobial Resistance. This review supports realignment of Maldives priority activities for the Antimicrobial Resistance programme and paves the way towards ensuring and enhancing the country's renewed efforts to combat antimicrobial resistance. I am pleased to note that this plan has been developed after thoroughly reviewing the current situation of the country and all activities planned. Thanks to the efforts of all partners, the plan was completed in a time-bound operational manner, following a mapping exercise conducted to identify funding gaps and resources mobilized for implementation. I commend the efforts, contribution and commitment made by numerous stakeholders such as Ministry of Health, Ministry Environment and Ministry of Fisheries and Agriculture For the foreseeable future, we must accelerate concerted action while continuing to increase national, regional, international, and global awareness and support towards Antimicrobial Resistance. Time is of the essence. The development of a new antimicrobial can take between 10-15 years and cost can exceed US$ 1 billion. Although Antimicrobial Resistance cannot be eradicated, it can be reasonably slowed down and contained. Therefore, WHO urges all stakeholders to continue their efforts into coordinating with the National counterparts to prevent, detect, and respond to the threat posed by Antimicrobial Resistance pathogens. As always, WHO remains a trusted technical partner to Ministry of Health and the Government of Maldives to support coordinated Dr Nazneen Anwar WHO Representa�ve to the Maldives environment. with the Global Ac�on Plan on An�microbial Resistance, adopted in 2015. etc. in the development and implementa�on of this updated plan. na�onwide efforts to combat An�microbial Resistance in the country. V Acknowledgement In 2019 alone, these infections led to over 1.27 million deaths globally. Rapid spread of antimicrobial resistance (AMR), combined with a lack of new treatments, has posed AMR serious global health threat. Recognizing this urgency, the Maldives adopted the World Health Organization's Global Action Plan (GAP) on AMR in 2015, becoming a regional leader in AMR containment efforts. The National Multisectoral Coordination Committee in 2016 initiated the first National Action Plan on AMR, achieving significant progress despite COVID-19 challenges, with five technical committees focusing on international standards. This AMR Action plan is the 2nd AMR plan of Maldives health sector which was formulated by the international consultant, Nazla M Luthfee, MD Msc. In 2023, a review of the National Action Plan on AMR led to the development of a second plan, focusing on strengthening governance structures and regulatory frameworks to enhance resilience and sustainability in managing AMR effectively. I take this opportunity to express sincere appreciation for the generous and continued support of the World Health Organization in developing this plan. The overall formulation process was a collaborative and a consultative effort by national stakeholders (Maldives Food and Drug Authority (MFDA), Quality Assurance and Regulation Department, Ministry of Health, Health Protection Agency (HPA), Ministry of Fisheries Marine Resources and Agriculture (MoAAW & MoFOR, Ministry of Climate Change, Environment and Energy (MoCCEE), Policy Implementation and International Relations Division ( PIIRD)). Consecutive meetings and discussions were carried out with stakeholders including public and private sectors by Maldives Food & Drug Authority. The text and format verified, and the numbering was done by Policy Implementation and International Relations Division under the supervision of Aminath Shaina Abdulla, the Deputy Director General of Policy Planning and International Health Division. The Cover page and the plan designed by Abdulla Shafraz, Political director The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. VI Execu�ve summary VII The Maldives has made significant progress in controlling and eliminating infectious diseases, including Tetanus, Polio, Leprosy, Malaria, Filaria, Measles, Rubella, and HIV/Syphilis transmission. This success is attributed to improved healthcare, sanitation, safe drinking water, and high vaccination coverage. In response to the WHO's call for action on Antimicrobial Resistance, a National Action Plan was formulated in 2017, covering 2017-2022.This initial plan, covering the period from 2017 to 2022, aligned seamlessly with the GAP AMR and delineated five primary objectives as follows: 1. Strengthen the knowledge and evidence base through surveillance and research. 2. Reduce the incidence of infection through effective sanitation, hygiene, and infection prevention measures. 3. Optimize the use of antimicrobial medicines in human and animal health. 4. Improve awareness and understanding of antimicrobial resistance through effective communication, education, and training. 5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines, and other interventions. In 2018, a comprehensive analysis of the NAP AMR 2017-2022 prevention and containment program was conducted, focusing on seven key areas: alignment with GAP AMR governance, awareness-raising, establishing a national AMR surveillance system, infection prevention and control, fostering research and innovation, and promoting One Health engagement. The analysis evaluated progress across 30 indicators and introduced 10 additional indicators for a more comprehensive evaluation. The 2018 situation analysis showed positive results, with indicators performing at or above phase 3. The 2023 situation analysis of the National Action Plan on Antimicrobial Resistance (NAP AMR) for 2017-2022 revealed similar findings with only three indicators performing at or above level 3. The country's commitment to the NAP AMR plan was evident, but the lack of a proper governance structure, a dedicated AMR coordination unit, and a National Multi-Sectoral Steering Committee contributed to the inadequate implementation. The absence of trained skilled human resources and a lack of surveillance in all sectors, including human, animal, agriculture, food, and environmental, further weakened the system. A fully functional national drug regulatory authority was established to oversee regulation, licensing, pharmacovigilance, and market authorization. Initiatives include developing national standards and guidelines, strengthening infection prevention and control measures, and updating environmental protection policies. However, there is limited awareness on AMR-related environmental impact or coordination among stakeholders on NAP AMR-related activities. The NAP AMR 2024-2029 aims to strengthen governance, enhance regulatory aspects across all sectors, and establish a communication pathway between stakeholders. It builds on the initial NAP AMR of 2017-2022, focusing on universal healthcare, animal welfare, food security, and a safe environment using the ONE HEALTH concept. The new objectives include establishing a National Multi-Sectoral Steering Committee and a National AMR Coordination Unit, digitalizing surveillance reporting, integrating AMR activities into existing programs, and developing a monitoring and evaluation framework. Abbrevia�ons and Acronyms Antimicrobial Agent Antimicrobial Resistance Antimicrobial Stewardship Programme Antimicrobial Use Antimicrobial Resistant Organism Antibiotic Susceptibility Testing Continuing Medical Education Essential Medicines List Food and Agriculture Organization Faculty of Health Sciences Global Action Plan Gross Domestic Product? Global Foodborne Infections Network Global Antimicrobial Resistance Surveillance System Good Manufacturing Practices Healthcare Associated Infection Health Protection Agency Infection Prevention and Control Committee Maldives Food and Drug Authority Ministry of Climate Change, Environment and Energy Ministry of Agriculture and Animal Welfare Ministry of Fisheries Ocean Resources Ministry of Health National AMR Coordination Committee National AMR Coordination Unit National Multi-Sectoral Steering Committee AMA AMR AMSP AMU ARO AST CME EML FAO FHS GAP GDP GFN GLASS GMP HAI HPA IPCC MFDA MoCCEE MoAAW MoFOR MoH NACC NACU NMSC VIII Background Introduc�on 1 The availability of effective antimicrobials have substantially reduced mortality and morbidity from infectious diseases and enabled multiple advancements in modern medical and veterinary practice '–(Australian Government 2015). The rise and spread of antimicrobial resistance (AMR) are creating a new generation of 'superbugs' that cannot be treated with existing medicines. The impacts of leaving AMR unchecked are wide-ranging and extremely costly, not only in financial terms but also in terms of global health, food sustainability and security, environmental wellbeing, and socio-economic development –'(HM Government 2019, World Health Organization 2023). Globally, unchecked antimicrobial resistance threatens many of the Sustainable Development Goals; such as ending poverty, ending hunger, ensuring healthy lives, reducing inequality, and revitalizing global development partnerships—are less likely to be achieved '(HM Government 2019). (Figure 1). According to World Bank unless AMR is contained an additional 28 million people could be forced into extreme poverty by 2050, through shortfalls in economic output (World Bank 2017). Already, AMR infections are estimated to cause 700,000 deaths each year globally. That figure is predicted to rise to 10 million, alongside a cumulative cost of $100 trillion, by 2050 if no Murray et al. estimated that 4·95 million deaths were associated with bacterial antibiotic resistance, including 1·27 million deaths attributable to bacterial AMR in 2019 (Murray, Ikuta et al. 2022). action is taken ref Table 1: Impact of AMR on SDGs Impact of AMR on SDGs '(HM Government 2019, World Health Organization 2021) AMR strikes hardest on the poor. Treatment of resistant infections is more expensive. Substandard care and partial treatment can drive infection Cost of AMR is predicted to be US$ 100 trillion by 2050, driving extra 28 million people into poverty Untreatable infections in animals t h r e a t e n s s u s t a i n a b l e f o o d production for growing populations It is crucial to balance access and conservation of antimicrobials with innovation, to contain AMR Antimicrobials are a component of all health systems. AMR will increase treatment costs, making effective c a r e u n a ff o r d a b l e f o r m a n y, and UHC unattainable. To effectively tackle AMR, collaboration and partnerships are needed across all relevant sectors and at all levels Lack of access to clean water and effective sanitation results in spread of infectious diseases; in turn, this increases antibiotic use and thus drives the emergence and spread of AMR. 1 NO POVERTY 2 ZERO HUNGER 3 GOOD HEALTH AND WELL-BEING 6 CLEAN WATER AND SANITATION 8 DECENT WORK AND ECONOMIC GROWTH 12 RESPONSIBLE CONSUMPTION AND PRODUCTION 17 PARTNERSHIP FOR THE GOALS Table 2: Five Objectives of Global Action Plan on AMR, 2015-2019 (World Health Organization 2015) 1. Strengthen the knowledge and evidence base through surveillance and research 2. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures 3. Optimize the use of antimicrobial medicines in human and animal health 4. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training 5.Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions The 2015 World Health Organization Global Action Plan and other international policy documents have stressed the need for a ''whole of United Nations approach'' in addressing antimicrobial resistance (AMR) (World Health Organization 2015). This action plan also emphasise the need for an effective “one health” approach involving coordination among various international sectors and actors, including human and veterinary medicine, agriculture, finance, environment, and well informed consumers (World Health Organization 2015). One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems. It recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and inter-dependent (World Health Organization 2021). One Health approach, linking humans, animals and the environment, addresses the full spectrum of disease control - from disease prevention to detection, preparedness, response, and management – and aim to improve and promote health and sustainability. 2 Figure 1: Schematic of potential transmission between human, environment and animal reservoirs — (Pattis, Weaver et al. 2022) 3 The antibiotics used to treat infections may be the same or similar in humans and animals; the manufacture, use, and disposal of antibiotics in all settings can potentially drive the emergence of resistance. When antibiotic-resistant bacteria arise, they may spread among humans, animals, and the environment. The WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) was launched in 2015 to foster AMR surveillance and inform strategies to contain AMR (World Health Organization 2022). The GLASS 2022 report highlighted effect of COVID-19 pandemic and reiterated the need to Enhanced collective efforts to ensure the continuity of crucial programmes such as AMR and AMC surveillance and to seize the opportunity to develop more sustainable infection prevention and control programmes, promote integrated antibiotic stewardship guidance, a n d l e v e r a g e i n c r e a s e d l a b o r a t o r y c a p a b i l i t i e s a n d o t h e r s y s t e m - s t r e n g t h e n i n g e ff o r t s (World Health Organization 2022). The GLASS 2022 report found an increase in AMR rates by more than 15% in 2020 compared with 2017 for meropenem and third-generation cephalosporin resistance in bloodstream E. coli BCIs, ciprofloxacin resistance in Salmonella spp. bloodstream bacteriologically confirmed infections (BCIs), and azithromycin resistance in gonorrhoea BCIs (Section 3.3). Although further studies would be needed to verify whether a real upward trend occurred for these combinations, the negative impact of the COVID-19 pandemic on both AMR surveillance activities and AMR rates has been reported previously and may have contributed, at least in part, to these findings. The very high 2020 levels of AMR in pathogens causing bloodstream infections, regardless of testing coverage, are of major concern. Third-generation cephalosporins are recommended as a first-line empiric treatment for this type of infection. High levels of third-generation cephalosporin resistance have been reported in Klebsiella pneumoniae, the third most frequent pathogen causing bloodstream infections, which may drive the increase in the use of 'last resort' carbapenems. Although the reported rate of carbapenems resistance in K. pneumoniae was lower in countries, territorials and areas (CTAs) with better testing coverage, the pooled rates from all reporting CTAs showed carbapenem resistance in more than 8% of bloodstream infections caused by this pathogen and may indicate the emergence of this type of resistance worldwide. The global spread of carbapenemase producing Enterobacteriaceae and the high rates of carbapenem and aminoglycoside resistance in Acinetobacter spp. (≥56% regardless of testing coverage) are of great concern. Carbapenem resistant isolates are usually multidrug-resistant and are often associated with treatment failure (World Health Organization 2022) Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella 4 pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000–1 270 000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths associated with AMR in 2019 (Murray, Ikuta et al. 2022). The broad benefits of AMR surveillance include the opportunity to introduce evidence-based policies and interventions data and information on levels and patterns of resistance. Such evidence based interventions in turn contribute to reduced disease burden, lower treatment costs, and reduced mortality (World Bank 2017). It is a concern that in many low-income settings where the threat of AMR is very high there is serious data gaps, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat (Murray, Ikuta et al. 2022). Though the Global Action Plan on AMR of 2015 while extensive in its scope some issues that have since emerged as it was not addressed include: governance, laboratory strengthening, the patient perspective and the need to integrate AMR into broader health systems such as primary health care, universal health coverage and pandemic preparedness (World Health Organization 2022). In response, WHO is now encouraging a programmatic public health approach that recognizes the interdependence of the six building blocks: political commitment and governance that brings leadership, funding, education, human resources and use of data; access to early diagnosis in a quality assured laboratory network; access to appropriate treatment; prevention of infection including IPC and vaccination; an uninterrupted supply chain for both treatment and diagnostics; and, surveillance and evidence generation. *Progress assessed for 20 indicators based on Situation Analysis was not conducted in DPRK in 2016 and compared in 2018 *progress assessed for 30 indicators (10 newly introduced indicators) based on Situation Analysis toll 2016 100 90 80 70 50 60 40 30 20 10 0 Bangladesh 40.0 P r o p o r ti o n o f in d ic a to r s in p h a s e 3 a n d a b o v e ( % ) Bhutan DPRK* India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand TLS Median progress 2016* 2018* 2018* 0 0 0 20 10 60 56.7 50 45 40.0 30.0 45 60 46.7 45 65 43.3 40 30.0 35 15 30.0 25 20 16.7 25 63.3 30 15 16.7 25 55 80 95 83.3 Figure 2: Progress of NAP-AMR implementation by country (2016-18) Situation analysis of NAPAMR implementation in SEARO region done on the basis of the 30 indicators (including the 10 additional indicators), The median country progress in 2018 was at 30% (on basis of 30 indicators assessed); maximum country progress was in Thailand at 83.3% and minimum in Nepal and Timor-Leste at 16.7% (World Health Organization 2019). Situa�on locally 5 The first NAP AMR was endorsed in 2016 the Maldives and released in the year 2017 as NAP AMR 2017 to 2022. The 2017 NAP on AMR was structured around the five strategic objectives and five principles which are embodied by the GAP AMR. Within the five strategic objectives of the GAP AMR, 12 specific objectives have been included. Each of these specific objectives has been described in terms of a Strategic Intervention, with a defined set of key activities to be carried out successfully to execute the strategic intervention and eventually to fulfil the strategic objective. Key Monitoring & Evaluation (M&E) indicators were listed for activities under each of the strategic interventions with the operational plan comprising of broad planning by activity. Formalized AMR multisectoral coordination mechanism with dedicated leadership, clear terms of reference, technical working groups, and adequate funding creates the basic foundation for NAP AMR implementation, AMR advocacy and sustainability. The NAP AMR 2017 states that the country response for Maldives will be mounted based on a well-appointed governance mechanism. Each of its aspects have been detailed with clearly assigned roles and responsibilities; this comprises of a High Level National Multi-Sectoral Steering Committee (NMSC), for Antibiotic Resistances. The NMSC will be supported by a National AMR Coordinating Committee (NACC) and multi-sectoral Technical Sub Committees (TSC) who will address the strategic objectives of GAP through specialised Working groups related to the five strategic objectives of GAP. The NAP AMR detailed out governance structure for its implementation with high- level National Multi-Sectoral Steering Committee (NMSC) chaired by Minister of health with involvement of other ministers from other relevant sectors was proposed. Unfortunately, the NMSC have not been formed and there is no dedicated unit in the country with dedicated staff to ensure NAP AMR implementation. NACC was formed and the technical committees and few meetings were conducted, but without a dedicated unit or staff support for the AMR program, and without a stronger political support, the country's implementation of NAP AMR lacks so far behind the targets. Global analysis of TrACSS indicators also shows there is a lack of a programmatic approach to NAP implementation with a focus on ad-hoc interventions, showcased by certain indicators having more progress over the years, while others have seen little to no progress. The report highlighted lack of leadership capacity to ensure the effective functioning of AMR multisectoral coordination structures in the country. Situation analysis by WHO was done on AMR related activities and NAP AMR implementation in 2016 and again in 2018 (World Health Organization 2019). Using the assessment tool used in 2018 current situation of analysis of 2023 was undertaken and comparison provided for the past two assessments done in 2016 and 2018 (table 3). The 2018 tool assessed the progress against 30 indicators as a proxy for strategic interventions/ programmes across eight focus areas. These included 20 indicators used in 2016 and 10 new introduced indicators). The focused areas of 2018 situational analysis tool included seven from the 2016 tool, are as follows:(1) NAP being in line with GAP-AMR governance; (2) raising of awareness; (3) national AMR surveillance system; (4) rational use of antimicrobials and surveillance of use/sales (community-based); (5) infection, prevention control and AMR stewardship; (6) research and innovation; and (7) One Health engagement. An additional area, (8) Overarching coordination mechanisms for One health engagement (was introduced in the 2018 tool). The situation analysis was undertaken in 2023 for development of the NAPAMR by consultation with stakeholders from, MoH-( MDFA, QARD, HPA), MoAAW & MoFOR, MoCCEE Similar to 2018 assessment report, Phase 3 or initial implementation was used as the minimum threshold for assessing progress. The key focus areas with the sub indicators were analysed against the five phases of implementa�on. Table 2: Phases of implementation · Phase 1: Exploration and adoption o Country initiates design of a program to combat AMR ·Phase 2: Program installation o The country decides to implement an AMR program after completing a set of core activities · Phase 3: Initial implementation o The country initiates an AMR prevention and control program at national level · Phase 4: Full operation o The country scales up to a successful model of an AMR program that utilizers accepted prevention and control programs. There is nationwide or large scale adoption of the program. There is evidence that the AMR program is functional and regularly generates outcomes · Phase 5: Sustainable program o The country operates its AMR program efficiently and there is 6 Assessment on the 8 key focus areas using theNAP AMR assessment tool 2018 are below Table 3: Situa�on analysis of NAPAMR implementa�on S.No Focus area and sub-indicators 2023 Explanation on the score change for 2018 to 2023 2018 2016 National AMR plan and governance1 NAP in line with GAP-AMR1.1 4 - 4 2 Raising awareness2 Campaigns to raise public awareness2.1 3 - 3 2 Education and training strategies for professionals2.2 3 3 1- National AMR surveillance system3 National Human AMR surveillance3.1 2 - 2 2 3.2 2 2 1 Early warning system3.3 1 1 1 Rational use of antimicrobials and surveillance of use / sales (community based)4 A national AMR containment policy for control of human use of antimicrobials: AMR stewardship 4.1 3 Stewardship policy and guideline document development but dissemination and implementation poor 2 2 - - National regularity authority or drug regulatory authorities 4.2 4 4 3- 4.3 3 3 2Monitoring of antimicrobial import being done and entered in GLASS-AMC since 2017 but not sales from pharmacies or utilization at facility or community level Surveillance of antimicrobial use and sales in human 7 Regulation of OTC sales and inappropriate sales of antibiotics and Apls by pharmacies Infection Prevention and Control and AMR stewardship program5 AMSP in healthcare setting5.1 2 In GMR assessed (n=2) AMS activity average score 42% peripheral: <10% (need better clarification from responders from Atoll) 1 1 IPC program in healthcare setting5.2 3 Central 2 major hospitals assessed 4 components (IPC program, leadership support, education and training and HAI score GMR (n=2) 84% Peripheral <10% 2 2 National HAI and related AMR surveillance 5.3 3 2 1 Sanitation and hygiene 5.4 4 - 4 2 Vaccination 5.5 2 1 NARota viral vaccine and pneumococcal vaccine in pipeline as per National Immunization program- NIP, Ongoing discussion to put influenza vaccine on Universal insurance scheme- Vaccination like COVID-19, influenza and optional (rota and pneumococcal) vaccine awareness and acceptance very good . Parent buy these vaccines currently. COVID-19 vaccination first, second, third and fourth dose 88%, 85%, 37% and 0.35% of above 12 years respectively (as per publicly release date on 10.6.23 via the o�cial the Health Protection Agency (HPA), Maldives, twitter account and viber group). 4.5 4 4 2- HAI prevention and surveillance guideline developed- one training conducted 8 4.4 3 - 4 2 Research and innovation6 R&D and innovation on AMR prevention, containment and research funding 6.1 1 AMR research priority areas not defined and there is no plan or budget dedicated for such research 2 1 7.1 3 Policy available, currently implementation not fully operational as per the policy and available guidelines 1 2 National surveillance of AMR ,and use and sale of antimicrobials at national level in the veterinary sector 7.2 AMU-2 AMR-1 AMU-2 AMR-1 3 Biosecurity (infection prevention and control) in the animal sector 7.3 2 1 1 AMR awareness generation and education in the animal sector 7.4 1 1 1- Monitoring antibiotic use in veterinary practice in installation phase One health engagment7 Policy and guideline available. In process of initiating the implementation A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management 7.5 1 1 NA- National surveillance of AR and AMR in waste water from manufacture and human/animal/fish use and disposal in institutions and the home 7.6 1 1 NA- Raising awareness on AMR and education in the environmental sector 7.7 1 2 NANo specific AMR awareness from the Environmental sector. Currently in exploratory phase Overarching coordination mechanisms for One Health engagement8 Overarching AMR coordination mechanisms between all relevant sectors 8.1 2 2 NA- 9 Inclusion and engagement of all relevant sectors in the NAP-AMR 8.2 1 - 2 NA A platform and/or mechanism for sharing of AMU monitoring data from all relevant sectors 8.3 1 - 1 NA A platform and/or mechanism for sharing of AMR surveillance data from al relevant sectors 8.4 1 1 NA AAW is nationally coordinated and celebrated, with involvement of and contribution from all relevant sectors 8.5 3 3 NA A mechanism for co-sharing of resources for AMR initiatives in the country 8.5 1 2 NA - Need better coordination between sectors specially to bring the environmental sector more on board Need to establish proper mechanism to share resources for AMR. Digitalization and inter sector/interdepartmental connection strengthening needed NA- not assessed 1+ - Discussion in Phase 2 allocation inconclusive 10 National AMR plan and governance Raising awareness National AMR surveillance system Rational use of antimicrobials and surveillance of use/sales (community based) Infection Prevention and Control and AMR stewardship program Research and innovation One health engagement Overarching coordination mechanisms for One Health engagement 2016 2018 2023 0 1 2 3 4 5 Situa�on analysis of progress in AMR preven�on and containment 2016 - 2023 Figure : Situation analysis in AMR prevention and containment (shows an average of phase-grading for all indicators in different focus areas; for 2016 using 20 indicators and for 2018 and 2023 30 indicators assessed), purely for pictorial representation Key findings from the Situation Analysis for 2023 Main points · Lack of poor governance structure for AMR related activity · Many regulatory provisions related to AMR in place or being established; implementational weakness noted in some areas which are already in place · Poor AMR related surveillance in all sectors (human, animal, agriculture, food and environmental) · Work being done for strengthening of IPC related measures in all sectors · Lack of monitoring and reporting framework for AMR related activities 11 There is lack of governance structure for NAP AMR activities as evidenced through lack of formation of a dedicated unit with dedicated staff for AMR related activities and lack of formation of High-level National Multi-Sectoral Steering committee (NMSC). Even without proper structural support MFDA and other stakeholders have undertaken some AMR containment efforts, evidenced through the formation of a National Multi-sectoral AMR Coordination Committee and initiation some NAPAMR stipulated activities. A fully functional national drug regulatory authority had been set up to oversee regulation and licensing, pharmacovigilance and market authorisation. Similarly, Water, Sanitation and Hygiene (WASH) related initiatives in human health along with high vaccination coverage were found to be significant infection control mechanisms within community settings. Compared to 2018 assessment improvement in areas of infection control initiatives in healthcare institutions by Ministry of Health Quality Assurance Division with the development of the national IPC and HAI prevention and surveillance guidelines (refer table 4). The Situation Analysis also threw light on other initiatives that are being taken to develop and draft national standards and guidelines, such as the national drug policies, updated essential medicines lists and standard treatment guidelines. Traditionally, lack of animal populations and commercial orientation of food animal production systems based on terrestrial animals has led to limited development and capacity of veterinary health services. Accordingly, majority of the food consumed in Maldives is imported into the country. Recently, the Government of Maldives laid emphasis on diversification into poultry and goat farming as well as aquaculture with the objective of attaining greater food security and the country have seen expansion of the veterinary health sector in the last few years. During the last two years agricultural and animal health sector have been working on policies and guidelines for strengthening infection prevention and control and antibiotic utilization measures in this field. These guidelines, which are planned to go for implementation soon, include; Guideline on Good Farming Practices In Aquaculture, Hatchery Sanitation Guidelines, Guidelines For Importation Of Hatching Eggs, Waste disposal related to animal farms; Collection, Procedure For Identifying Disease Area And Quarantine Area And Disease Reporting, Preservation and transportation of specimens for Laboratory diagnosis of Animal Diseases; Establishment of central and regional Veterinary Investigation and Diagnostic Laboratory network etc. During the discussion with stakeholders, it was noted that the environmental sector, MoCCEE, is in the process of updating different policies and guidelines related to environmental protection including proper waste management system in the country, though currently there is limited awareness on AMR related environmental surveillance and therefore no plans in pipelines for such in the country. Strengthening surveillance for AMR in human, animals, food industry and environment require one health concept, with improved coordination, knowledge and data sharing between these sectors. Efforts from all sectors clearly highlighted strong elements that having potential to be leveraged as building blocks for an effective NAP AMR implementation and emphasize the need for proper infrastructural support system to coordinate, update and sustain these activities. 12 Antimicrobial resistance is a multifaceted problem and requires a comprehensive response. Considering the crosscutting nature of the problem and its wider implications, efforts must be made from all stakeholders to prevent and contain resistance. There is a need to strengthen the national level response to AMR and ensure the implementation of National action plan and national policies to ensure rational use of antimicrobials. This national action plan shall help in prioritizing the limited national resources, strengthening the governance structure and promote a united drive against AMR. This national action plan shall be applicable to all sectors related to human health, animal health and agriculture practice dealing with antimicrobials. In addition, this action plan is applicable to the environment sector which relates to impact of antimicrobials released into the environment. The future actions and activities on AMR shall be within the strategies outlined in this document The national action plan is based on the following guiding principles: 1. Awareness of the antimicrobial resistance at the global, regional and national level 2. Promoting the rational use of the available antimicrobial agents; 3. Preventing emergence of resistance through appropriate control and regulatory measures; 4. Changing the behaviour of the prescribers and communities in the use of antimicrobials; and 5. Promoting the active participation of various stakeholders and bringing them on board to take ownership in the national effort Considering the key findings from the 2023 situational analysis of NAP AMR 2017 implementation, the main changes brought to the current NAP include; · Addition of 2 more main objectives in addition to five already in the NAP as per GAP oE stablishment of governance structure for AMR oS trengthen implementation of regulatory aspects of NAP AMR ·E stablishment of National AMR coordination unit (NACU) in MFDA with relevant staff including AMR program manager and Assistant AMR program manager ·E stablishment of National AMR Steering Committee and AMR Coordination Committee to be chaired by representative from main stakeholders on a rotational basis (MoH, MOAAW, MOFOR and MoCCEE) ·I ntegrate AMR related activities into the other existing programs to function with support and guidance from related technical subcommittees. ·E stablishment of a communication pathway from stakeholders to main National AMR coordination unit (NACU) in MOH and vice versa. ·E stablishment of AMR related surveillance reporting pathway and mechanism for analysing and data sharing ·D eveloped the Monitoring and evaluation frame work with measurable out comes for each activity in NAP AMR 13 Objec�ves While developing the NAP-AMR for Maldives, a strategic plan has been formulated, keeping in mind its geographical aspects as also its public health and other socio-cultural and economic status. The NAP AMR has been based on the implementation of seven strategic objectives, each of which has its objectives, strategic interventions and key activities: Objective 2: Strengthen the regulatory system related to AMR Objective 3: Improve awareness and understanding of AMR through effective communication, education and training Objective 4: Establish Surveillance and monitoring system for AMR Objective 5: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures Objective 6: Optimize and monitor use of antimicrobial medicines Objective 7: Develop the economic case for sustainable investment by taking into account the needs of the country regarding new medicines, diagnostic tools, vaccines, research, and other interventions 14 15 Objective 1: Establish Governance structure for NAPAMR implementation The country response for Maldives will be mounted based on a well-appointed governance mechanism as proposed in the NAPAMR 2017 with some additional key changes included in the structure i.e. formation of the National AMR coordination unit (NACU) in MFDA and integration of some activities into existing national programs. NACU will be responsible unit for overall coordination and monitoring of NAP AMR implementation and NACU will report to National AMR Coordination Committee (NACC). A focal person each for human and animal health shall be designated to provide technical assistant related to functioning of NACU. The focal person of the MoH shall act as the national focal point for AMR A national multi-sectoral governance mechanism will serve as the central intervention around which all the AMR-related activities occur, ensuring a one health approach by formation of the National Multi-Sectoral Steering committee (NMSC) at the top. The NMSC will be supported by a National AMR Coordinating Committee (NACC) and multi-sectoral Technical Sub Committees (TSC). The TSC depending on its role will be linked to lead agencies implementing the objectives and TSC may seek to form special Taskforce to address any issue. Each of its aspects have been detailed with clearly assigned roles and responsibilities. Implementation of the NAP AMR and its associated committees will be supervised by NACU. Table : Objective 1- Establish Governance structure for AMR implementation Strategy Activities Performance indicator Target Timeline Lead agency Objective 1: Establish Governance structure for NAPAMR implementation Implementing partners 1.1 The government shall allocate adequate resources for the operationa- lization of the National Action Plan 1.1.1 NAPAMR 2024-2029 released 1.1.1.1 NAPAMR 2024-2029 endorsement by Minister of Health after proper sensitization and advocacy (targeted for all relevant policy level stakeholders) 1 4Q2024 MoH QARD, MFDA, HPA, MoAAw & MoFOR, MoCCEE, MoHE, MoF, MoE1.1.1.2 NAP AMR disseminated Awareness session for main four stakeholders. Online access, Print 100 4Q2024 QARD,HPA, MoAAw & MoFOR, MoCCEE, MoHE, MoF, MoE 1.1.2 Develop a budget plan for implemen- tation of NAPAMR activities (including monitoring and evaluation) and identify funding sources 1.1.2.1 Consultation with key stakeholders undertaken to develop costed budget plan WHO costing and budgeting tool) 1 4Q2024 1.2.1 Institute National multi- sectorial steering Committee for AMR 1.2.1.1 TOR of NMSC updated and endorsed by Minister of Health 1 4Q2024 MFDA Minister of Health 1 MoH, MFDA, QARD, HPA, MoAAW & MoFOR, MoCCEE, MoF, MoE 1.2.1.2 NMSC formed and endorsed by Minister of health 1.2 A High Level National Multi Sectorial Steering Committee (NMSC) shall be instituted at the highest level of the government for policy related decisions 16 NMSC NACU MFDA MoAAW & MoFOR MoCCEE MoE MoHE MoH HR 1.3.1.1 ToR for the NACU developed & endorsed by MoH 4Q2024 4Q2024 MOH MFDA 1 QARD, HPA, MoAAW & MoFOR, MoCCEE, 1.2 A High Level National Multi Sectorial Steering Committee (NMSC) shall be instituted at the highest level of the government for policy related decisions 1.2.2 Conduct Steering Committee meetings 1.2.2.1 Number of meetings conducted NMSC Minimum 8 (bi-annually) 4Q2024 (starting date) 1.2.2.2 Costed budget plan endorsed by NMSC 1 4Q2024 1.2.2.3 Number of documents endorsed & reviewed 8(1 per meeting) 4Q2024 (starting date) 1.3 There shall be a designated National AMR Coordination unit (NACU) within MoH with provision of adequate infrastruct- ural support 1.3.1 National AMR Coordination Unit (NACU) established in relevant department of MoH with proper communication pathway between NACU and other stakeholders 1.3.1.2 Provision of adequate number of sta in NACU 4Q2024 4Q2024 1 2 technical & 1 admin sta (minimum) 1 1.3.1.3 Develop and online integrated platform for AMR related data collection Minister of Health MFDA 1.3.2 Designate AMR focal points in relevant agencies to support NACU 1.3.2.1 FP in MFDA (National AMR focal Point and from Human health) 4Q20241 MFDA MoAAW, MoCCEE 1.3.2.2 FP from MoAAW, MoFOR & MoCCEE (from animal/plant health & environment) MFDA MoAAW & MoFOR MoCCEE MoE MoHE MFDA MoAAW & MoFOR MoCCEE MoE MoHE 17 1.4 Form the AMR National coordination committee (NACC) and TSC. NACC function to advise the government on all matters related to AMR 1.4.1 Re-establish AMR National coordination committee (NACC) 1.4.2 Develop TSC 1.4.3 Conduct regular meetings of NACC 1.4.1.1 Endorse NACC TOR by NMSC 1.4.2.1 Develop the 5 relevant TSC according to NAPAMR structure 1.4.1.2 Identify members of NACC and hold first meeting of NACC 1.4.2.2 Establish lead agencies to collaborate with TSC according to NAPAMR structure 1.4.3.1 Number of meetings held 1.4.3.2 Endorsed documents / recommendations given 1 1 4Q2024 MFDA NACU QARD, HPA MoAAW & MoFOR, MoCCEE MoE, MoHE 1 1 14 (minimum) 14 (1 per meeting) 4Q2024 4Q2024 4Q2024 (start date) NACC MACU NACU MFDA QARD HPA MOAAW & MOFOR MoCCEE MFDA 18 National Multi-sectoral Steering Committee (NMSC) National AMR Coordination Committee (NACC) National AMR coordination Unit (NACU) Secretariate Awareness TSC Surviellance TSC IPC & Hygine TSC AMU TSC Sustainable investment in Research, innovation & new interventions TSC Task force (formed as needed) ................................................................................................................................................................................. ......................... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. . Figure : NAP AMR Governance Structure Ministry of Health Ministry of Agriculture & Animal Welfare Ministry of Fisheries and Ocean Resources Ministry of Climate Change, Environment & Energy Ministry of Education Ministry of Finance .......................................................................................... .. .. .. .. .. 19 Na�onal Mul�-Sectoral Steering Commi�ee (NMSC) for An�microbial Resistance Composition of NMSC The NMSC will be chaired by Minister for Health and Co-Chaired by Minister of Fisheries and Ocean Resources and Minister of Agriculture and Animal Welfare. Its membership will be as follows: Minister of Health (Chairman) or Ministers representative Minister of Minister of Fisheries and Ocean Resources or Ministers representative Minister of Agriculture and Animal Welfare or Ministers representative Minister of Climate Change, Environment and Energy or Ministers representative Minister of Education or Ministers representative Minister of Finance or Ministers representative or Ministers representative Logistics of the NMSC National AMR Coordinating Committee (NACC) The NMSC will provide the necessary political commitment and support for national AMR containment efforts in Maldives and to the international global health community. Given the ultimate goal of AMR containment efforts that are geared to improve human health outcomes, the NMSC will be formed under the leadership of MoH with Minister of Health as the Chairperson. The NMSC will meet bi-annually when it will be appraised of AMR control efforts in the country. NMSC will provide necessary political support to avail financial and human resource for programme implementation. The secretariat of NMSC will be National AMR Coordination Unit (NACU) in MFDA and the technical support will be provided by National AMR Coordination Committee (NACC). The NACC will be support and monitor NACU in implementation of NAP AMR and will draw its powers and mandate from the Decree by Minster of Health while NMSC will provide strategic vision to AMR control efforts. The NACC will provide the platform for programme planning and implementation through a supporting structure comprising of stakeholders in relevant ministries and technical working groups for individual strategic objectives. The NACC is envisioned as a multi-sectoral group of senior officials from different ministries with adequate representation of non-governmental agencies, cooperatives, civil society representatives, media, international agencies (WHO/FAO/OIE). By way of its multi-sectoral composition, it will ensure adequate integration of AMR containment efforts into the existing health system, public health and disease-specific programmes, animal health and food production sector and other environmental initiatives. The chair and vice chair will be appointed by the Minister of Health, and its Secretariat will be NACU in MFDA. Its membership will be drawn from the: 20 Logistics of the NACC · Ministry for Health (MFDA, HPA, QARD) (CORE members) ·M inistry of Fisheries and Ocean Resources (CORE members) ·M inistry of Agriculture and Animal Welfare (CORE members) ·M inistry of Climate Change, Environment and Energy (CORE members) ·M inistry of Education (CORE members) ·M inistry of Finance (CORE members) ·R egulatory authorities- EPA, Utility Regulatory Authority (with ENVIRONMENT) ·P rofessional associations Maldivian Medical Association, Nursing and Allied health association, animal health, environmental association and relevant councils. ·R epresentatives from major hospitals to include at least one Microbiologists, ID specialist consultant (x2) IPC nurse(x1) ·R epresentative from NRL ·V eterinarian · Academia representative x 1 MNU,1 Villa (1 count as one for quorum) Note: Committee can be amended or revised as per functionality within THE 5-year period. Quorum to be finalize in NACC first meeting and to decide the core members and non-core members). Suggested: Core members should include those from the relevant ministries and representative from clinical background x 2 (minimum). The NACC will meet regularly once every 4 months and or as required. The NACC will have a rotatory Chairmanship between Ministry for Health, Ministry of Fisheries and Ocean Resources and Ministry of Agriculture and Animal Welfare. The rotation will happen annually. If any member is unable to attend 3 consecutive meetings of the committee NACU needs to inform the relevant ministry/organization. Roles and responsibilities of NACC: Roles and responsibilities of the NACC have been mentioned in the Strategic Plan. Broadly, it will be responsible for: · Finalise the NAP AMR Operational plan and budget Planning, monitoring & evaluation of different strategic interventions and activities of NAP AMR ·S upport NACU on the implementation, coordination and monitoring of NAP AMR objectives ·C onstitute technical working groups for main objectives that include providing technical input for program support and decision-making ·F acilitate collaborations with internal and external agencies and organizations in the field of surveillance and innovations ·A dvocate for prevention and containment of AMR 21 22 National AMR Coordinating Unit (NACU) The National AMR coordination unit (NACU) in MFDA will be the implementation agency for NAP AMR objectives. The NACU will provide the platform for programme implementation, coordination and monitoring with support from the National AMR Coordination committee (NACC). NACU will also act as the secretariat for NMSC and NACC. The AMR program manager in NACU will be overall responsible for the functioning of NACU with support from NACC and NMSC The main functions of NACU are: · Act as the main coordination unit and responsible for regular monitoring and evaluation of NAP AMR implementation ·E nsure regular data collection and information sharing by instituting effective communication and coordination among all stakeholders, the members of NACC and their constituencies, sectors and disciplines; ·C oordinate national activities for establishment of AMR surveillance systems ·R eporting implementation status to NACC, national agencies and international partners as required including Report on prevalence of and trends in AMR to the global AMR surveillance system (GLASS) ·L ead the drafting and update of a national action plan for containment of AMR ·P rovide secretariate support to NACC, NMSC and all TSCs Composition (minimum requirement) · AMR program manager (technical background) ·A MR assistant program manager (technical background) ·A dmin support at least one Appointing a National Focal Point National AMR focal (National F.P) will be assigned by MoH. National F.P point shall be responsible for coordinating AMR activities and tasks in the health, animal, fisheries, food production and environment sectors. The responsibilities of NFP will be to: · Build sustained partnerships and work nationally and internationally on containment of AMR; ·I dentify stakeholders and facilitate formation of an inclusive NACC ·S upport and facilitate formation of the National AMR coordination unit (NACU) with appointment of AMR program manager, assistant program manager and admin support for the unit. ·S upport NACU on drafting of a national action plan for containment of AMR ·M onitor and support the regular data collection and information sharing and facilitate provision of required resources to NACU ·S upport and advocacy for AMR related activities Forming Technical Sub Committees 23 Technical Sub Committees (TSC) will form an integral part of the governance mechanism in Maldives. These will be multi-sectoral in composition and will report to the NACC. They will be formed as a priority and will be mandated with specific tasks such as providing technical input, conducting situational analysis, assist in drafting NAPs, support agencies in planning and budgeting, commissioning specialised working groups and overseeing implementation of strategic interventions and corresponding key activities under the five objectives of GAP in the NAP. The Chairperson of each TSC will automatically become a member of NACC. The proposed thematic TSCs that will be formed include: 1. Awareness 2. Surveillance 3. Infection Prevention and Control and Hygiene 4. Optimizing Antimicrobial Use 5. Research and Innovation Each of the TSCs will be responsible for supporting the lead agencies in programme planning and budgeting referring to NAP on AMR while focusing on One Health and for coordinating between the different agencies and secretariat. They will be responsible for monitoring and evaluation and based on their interactions and review mechanisms come up with a set of workable recommendations for the relevant key agencies. The 5 TSCs will be mandated by the NACC and will report to their chairpersons and to the AMR program manager in NACU. The organisational structure, composition, locus of coordination centre and general terms of reference are listed below. Specific jobs of individual TSCs have been detailed in the Strategic Plan document. If any member is unable to attend 3 consecutive meetings of the committee, NACU needs to inform the relevant ministry/organization. General Terms of references of Technical Sub Committee Technical Sub Committee (TSC) will be multi-sectoral in composition and will report to the NACC. In their respective strategic objective, the TSC will: · Implement proposed activities by the National AMR Coordination committee in line with NAP ·D raft detailed annual plan and revise annually at sub activity level NAP ·P rovide strategic direction by identifying intervention and key activities ·C onduct situational analyses ·S upport lead agencies in planning and developing budget for different activities ·M onitor and evaluate implementation of strategic interventions and corresponding key activities ·P rovide technical input ·C ommission specialised working groups working groups Specialised working groups will be commissioned by the TSCs for delivering on specific tasks in the respective strategic areas. The working groups will work under technical guidance and supervision of respective TSC and will comprise of in-country as well as international experts, including those from WHO/FAO/OIE. The Working groups will be tasked with functions such as evaluation of existing policies, frameworks, interventions and guidelines and the development of guidelines and standards. Integration of NAP AMR activities into existing programs/activities Lead agencies and supporting agencies will be identified for implementation of each of the main 7 objectives of NAP aim to integrate the activity into existing programs where possible. The lead agency will be responsible for implementation of the specific component of the NAP AMR objective, programme planning and budgeting while focusing on One Health approach. The lead agencies will be supported by TSC for implementation of the 5 main GAP objectives in NAP AMR as mentioned before. Table 5 : NAPAMR objectives and responsibilities of stakeholder agencies S.No Objective Lead Agency for implementation Supporting agencies implementation support Establish governance structure for AMR MoH-MFDA/NACU QARD, HPA, MoAAW & MoFOR, MoCCEE, MoE, MoF NMSC (Monitored by NACC) Strengthen the regulatory system related to AMR MFDA- MTG (Human) MoAAW & MoFOR: (Terrestrial, marine and aquatic animals & Plants) MoCCEE: environmental MFDA-Food safety NMSC (Monitored by NACC) Improve awareness and understanding of antimicrobial resistance through e ective communication, education and training NACU QARD, HPA MoAAW & MoFOR, MoCCEE MoE, Associations, MNU, NGO/ Red Cresent TSC for Awareness Strengthen the knowledge and evidence base through surveillance NACU QARD (HAI), MoAAW & MoFOR, MoCCEE, MFDA-Food safety HPA-disease TSC for Surveillance Reduce the incidence of infection through e ective sanitation, hygiene and infection prevention measures QARD/ NACU (IPC & patient safety incident reporting system) HPA (WASH), MFDA-food safety, MoAAW & MoFOR, MoCCEE TSC for IPC and hygeine Optimize use of antimicrobials QARD & MTG MoAAW & MoFOR, MFDA TSC for optimizing antimicrobial use Sustainable investment in research, innovation and new interventions. NACU QARD, HPA, MoAAW & MoFOR, MoCCEE, MoE, Associations, MNU, Villa College TSC for research and innovation 1 2 3 4 5 6 7 24 Objec�ve 2: Strengthen The Regulatory System Related to AMR The regulatory process of ensuring quality, safety and efficacy of antimicrobials in the country shall be implemented. Antimicrobial use in animal feeds and other non-therapeutic uses shall be restricted and the discharge of antimicrobial compounds into the environment shall be regulated. Define the regulatory role of: 1. MFDA 2. QARD 3. HPA 4. MoAAW 5. MoFOR 6. MoCCEE 7. URA (Utility Regulatory Authority) 25 Strategy Objective 2: Strengthen the regulatory system related to AMR Activiteis Performance indicator Target Time line Lead agency Implementing partners 2.1 Strengthen regulatory provisions on import, sale and storage of antimicrobials in human, animal health, agricultural practices and environment 2.1.1 Update the national AMR containment policy (of antimicrobials in human, animal health, agricultural practices and environment) and organizational framework within the charter of the Policy 2.1.1.1 Develop a national AMR containment policy and propose a formal organisational structure responsible for implementation of the National AMR containment policy. The Policy will mandate provisions for the five strategic objectives enshrined in GAP and NAP AMR for Maldives 1 1Q2025 NACU MOH, MoAAW & MoFOR, MoCCEE, URA 26 Table 6: Objective 2- Strengthen the regulatory system related to AMR 27 2.2.1 Ensure availability of essential antibiotics 2.2.1 Audit on availability of essential antimicrobials in market (as per the essential antimicrobial list-EAL) 80% of EAL available in market central and peripheral (take represent- ative sampling method) Start 2024 MoH (QARD, MTG-MFDA) NACU MoH procurement Board run hospital MoAAW & MoFOR QARD 2.2 The antimicrobials in the country shall be appropriate and of proven quality, safety and e�cacy 2.2.2 Approve market authorization for antimicrobials based on evidence of safety and e�cacy and GMP audit of the manufacturers. 2.2.2.1 Market authorization issued and GMP audit reports Annual Audit report: showing 100% of medications used are GMP verified Annually (from 2025) MTG-MFDA NACU MoAAW & MoFOR QARD 2.2.3 Conduct QC testing of antimicrobials 2.2.3.1 Antimicrobials tested Sampling of antibiotics done according to approved sampling method (including Annual target defined by TSC (from 2025) MTG-MFDA and MFDA-NHL NACU MoAAW & MoFOR QARD 28 2.3 The non-therapeutic use of antimicrobials in animal feed and agricultural practice including residues in food products shall be restricted 2.3.1 Regulatory provision for non-therapeutic use of antimicrobials in animal feeds/ as growth promoters 1 2.3.1.1 Include Regulatory provisions for non-therapeutic use of antimicrobials in animal feed in place 2Q2025 MoAAW & MoFOR MFDA and NACU 2.4 Regulate antimicrobial compounds discharged into the environment 1 2Q2025 29 2.5. Institute an e�ective overall M&E system of the NAP AMR components 3 1Q2025 30 1 2Q2025 10 1 Strategic Objective 3: Improve awareness and understanding of AMR through e�ective communication, education and training 31 The GAP AMR has identified the need to raise awareness of AMR and promote behavioural change through public communication programmes that target different audiences in human health, animal health (terrestrial, aquatic and marine) and agricultural practices as well as a wide range of consumers related to these sectors. The GAP AMR has also focused on making AMR as a core component of the professional education training, certification, continuing education and development in the health and veterinary sectors and agricultural practice. This approach is expected to foster proper understanding and awareness amongst professionals. The Situation Analysis in Maldives revealed that awareness campaigns on AMR have initiated by MFDA. Awareness campaigns have been targeted to including general public and professionals in health sector and to some level AMR related awareness has been targeted to animal and food safety sector during antimicrobial awareness week. Introduction of AMR in curricular interventions in schools has been started and some work has been done to incorporation AMR related materials into curriculum of health and allied health services. Regarding animal health and agricultural practices guidelines related to IPC and AMR in livestock and fisheries sectors are being finalized and following which conduction of awareness and training sessions for those in this field has been planned from MoAAW & MoFOR Activities related to the third objective “Improve awareness and understanding of AMR through effective communication, education and training “will depend on the communication plan. The following activities and timeline give a suggestion for the way forward and minimum targets. Table 7: Objective 3- Improve awareness and understanding of AMR through effective communication, education and training Strategy Objec�ve 3: Improve awareness and understanding of AMR through effec�ve communica�on, educa�on and training Activiteis Performance indicator Target Time line Lead agency Implementing partners 3.1 The public education and awareness shall be promoted through appropriate medium on AMR related topics; AMR, IPC, hygiene (WaSH), food safety, vaccination in human and animals etc. 3.1.1 Update the AMR communication and education strategy 3.1.1.1 Update and endorse the AMR communication and advocation strategy by AMR NACC 1 2Q2025 NACU Supported by Awareness & Education TSC MFDA, QARD, HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE 3.1.1.2 Develop and endorse AMR communication plan with targets for 2025-2029 3.1.1.1 TV program developed and aired 8 Bi- Annually (from 2024)8 3.1.1.2 Radio Program developed and aired3.1.1 Develop TV/radio Program on AMR and broadcast MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE 3.1.2 Design, develop designated social media profile for AMR 3.1.2.1 Twitter handle for AMR Maldives 1 3Q2025 50 3.1.2.2 Number of social media posts designed, developed, and released From 2024 monthly one MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE 3.1.3 Utilization of influential personalities for AMR awareness 3.1.3.1 Number of AMR ambassadors (Social media influencers, community and political level influencers) from di�erent key areas 3 5 years (depend on comm- unication strategy) MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE 3.1.4 Create awareness among 3.1.4.1 Awareness sessions for school Cover 60% of schools Annually (from 2025) MFDA, QARD 32 students, teachers and sta� 3.1.4.2 Awareness sessions for students 3.1.4.3 implementation of the AMR content in curriculum Cover 60% of schools Annually (from 2025) HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE 3.1.4. Observe Antibiotic awareness week 3.1.4.1 Awareness week observed 4 Annually (from 2024) MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE 3.2.1 Incorporate in Undergraduate and post graduate curriculum for health-related fields (animal, human and environment) 3.2.1.1 AMR should be a core component in the syllabus of all relevant higher education programmes Human health x 5 fields Animal x 1 Agricult- ure x1 Environ- ment x 1 field 4Q2027 MoE, MoHE QARD, Nursing Council, Medical & Dental Council, Allied health council 3.2.2 CME on AMR related topics for professionals (human and animal health)- physical or online depend on communication plan 3.2.2.1 No of CMEs healthcare institutes. Depend on communication plan- develop/ provide access to online platform for healthcare professions CME on AMR 3.2.2.2 Healthcare facilities conducting regular AMR related CMES > 50% of hospitals Start 2025 8 (minimum) for all hospitals Biannually (start 2025) MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE, Nursing Council, Medical & Dental Council, Allied health council 3.2.3 Educational sessions to relevant stakeholders in ministries 3.2.3.1 Number of AMR related sessions for MoH, MoAAW & MoFOR, MoCCEE, MoE sta� 4 Annually MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE, MoE, MoHE, disaster, defense 3.2 Education and training of healthcare and professionals 33 3.2.4 Evaluate and ensure AMR related fields are incorporated in the training priority list for the country 3.2.4.1 Conduct a needs based assessment to develop human capacity for AMR related fields (for eg: Microbiology, Infectious diseases, Clinical Pharmacy, Infectious control nurse training, CSSD technicians, veterinarian, Food safety specialist, environment scientists etc.). priority list developed training in AMR related fields and shared with relevant authorities: 1 3.2.4.2 Ensure that the priority fields are included in annual training opportunities announced by Ministry of Higher Education 1Q2025 MFDA, QARD HPA, MoAAW & MoFOR, MoCCEE 3.3 Information on IPC, AMR and antimicrobial stewardship (human and health) for sta� in healthcare and other relevant institutes 3.3.1 Develop AMR related content for sta� orientation program at the time of joining (hospitals, pharmacy, clinics, institutes etc. related to human and animal). This maybe an online platform for sta� to participate. 3.3.1.1 AMR module developed for In-service orientation 1 (human) 1 (animal) 2Q2025 MFDA QARD HPA MoAAW & MoFOR MoCCEE MFDA QARD HPA MoAAW & MoFOR MoCCEE Annually from 2025 > 50 % of newly joined sta� from health care facilities 3.3.1.2 Participation of newly joined healthcare sta� 34 3.3.2 AMR sessions for sta� in key agencies 3.3.2.1 Number of AMR related sessions for MoH, MoAAW & MoFOR, MoCCEE, MoE sta� 20 Annually from 2025 MFDA QARD HPA MoAAW & MoFOR MoCCEE 3.4.1 Evaluate e�ectiveness of AMR related trainings and awareness activities through e�ective evaluation tools 3.4.1.1 KAP studies on AMR awareness 4 Annually from 2025 3.4.2 Evaluate cultural drivers of health-seeking and health-providing behaviours, which a�ect the management of drug-resistant infections and patient outcomes 3.4.2.1 KAP study to evaluate cultural drivers of health seeking and health providing behaviour 35 Strategic Objec�ve 4: Establish Surveillance and monitoring system for AMR · Descriptive epidemiology of resistant organisms as they emerge ·U nderstanding how resistance develops and spreads ·T he ability to rapidly characterise the emergent resistant organisms ·U nderstanding social sciences, behavioural and other research needed for holistic fulfilment of all five strategic objectives ·T reatment and prevention of infections, especially in the low resource settings ·B asic and translational research to support the development of new treatments, diagnostic tools, vaccines and other interventions ·A lternatives to non-therapeutic uses of antimicrobial agents in the context of agriculture, aquaculture and their use in crop protection ·E conomic research The situation analysis revealed that several elements of systematic AMR surveillance are not in place in different sectors such as required surveillance standards or guidelines, laboratory standards, systematic data collection and analysis including electronic reporting, recording and linkage with HAI surveillance. Human health sector is ahead with an institutional level bacterial AST and initial efforts to put quality assurance system in selected laboratories performing AMR testing. However, animal health sector has no AMR surveillance in the emerging food animal production systems of poultry, goat farms and aquaculture. Maldives will consolidate and strengthen the AMR surveillance. Initially by strengthening the current lab-based reporting from healthcare institutes for informed decision and amend policies. It is planned to develop a high-quality AMR surveillance system that will integrate AMR surveillance in laboratories, hospitals, AMU and surveillance in animal and environmental sectors by second quarter of 2025, together with mechanism for early warning system for timely identification of emergence of resistance in priority pathogens and to cr i t ica l ant imicrobia ls . The Plan wi l l be rol led out as below: 36 The GAP AMR identifies the need to establish evidence-based surveillance for AMR in the nation and identifies the following critical information/evidence gaps: Table 8: Objective 4- Establish Surveillance and Monitoring System for AMR Strategy Objec�ve 4: Establish Surveillance and Monitoring System for AMR Activiteis Performance indicator Target Time line Lead agency Implementing partners 4.1.1.1 Microbiology testing facilities equipped and strengthened All hospitals 1Q2025 4.1 Lab-based AMR surveillance shall be established 4.1.1 Establish Microbiology testing facilities at all major Hospitals/Labs (including government and private) QARD 4.1.1.2 No. of Lab personnel trained 2 from each hospital Annually QARD 4.1.1.3 Adherence to National Clinical laboratory Standard 50% of govern- ment/ 20 % private 4.1.1.4 Participated in External quality assessment 20% gov- ernment Annually 1Q2025 QARD QARD 4.1.2 Lab based AMR surveillance training and networking 4.1.2.1 Develop SOP on lab-based surveillance, with defined priority pathogens and mechanism for early detection of outbreaks 1 1Q2025 QARD/HPA NACU 4.1.2.2 No. of training conducted 3 (from 2024) Annually QARD/HPA 4.1.2.3 Lab testing standardized 100% 2025 Annually QARD 4.1.2.4 Number of labs releasing monthly antibiograms IGMH & ADK (with loc- ation OPD/ IPD) 3Q2024 QARD/HPA Other hospitals to release monthly antibiogr- ams (with location IPD/OPD) 4Q2027 37 4.2 Lab-based antimicrobial residual surveillance shall be established in food and food products 4.2.1 Strengthen antimicrobial residual testing facilities for food products 4.2.1.1 antimicrobial residual testing facilities equipped 1 3Q2025 MFDA-NHL and food safety 4.2.1.2 No. of Lab personnel trained 2 (minimum) 3Q2025 MFDA-NHL and food safety 4.2.1.3 Sampling guideline and testing SOPs developed and sensitized 2 3Q2025 Food Safety MFDA/NHL 4.2.1.4 Procure updated editions of AOAC/IS 3 3Q2025 Food Safety MFDA/NHL NACU 4.2.1.5Subscribe to External Quality assessment (PT/ILC) and procure QC sample 3 4Q2025 3Q2025 Food Safety MFDA/NHL 3 4.2.1.6 Reports generated on level of antibiotic residue in food and food products Food Safety MFDA/NHL 4.3 Lab-based Antimicrobial residual compound and resistance pathogens shall be established in the environment 4.3.1. Develop national risk assessment framework for antimicrobial compounds and antimicrobial resistant pathogens in environment 4.3.1.1 Develop national risk assessment framework for antimicrobial compounds and resistant pathogen testing in the environment integrated with surveillance in humans, animals and plants 1 1Q2025 MoCCEE NACU MoAAW & MoFOR MFDA HPA QARD 4.3.2 Strengthen antimicrobial 4.3.2.1 AMR residual testing facilities equipped 1 4Q2025 MoCCEE NACU MFDA-NHL 38 compounds and their residues testing from environment 4.3.2.2 No. of Lab personnel trained 2 1Q2025 4.3.2.3 Sampling guideline and testing SOPs developed and sensitized 1 1Q2025 4.3.2.5 Subscribe to External Quality assessment (PT/ILC) and procure QC sample 5 Annually (from 2025) 4.3.2.5 Reports generated on level of antimicrobial compounds and resistant pathogens environmental samples 5 Annually (from 2025) 4.3.3.1 Sampling guideline and testing SOPs developed and sensitized 1 2Q2025 4.3.3.2 Reports generated on antimicrobial resistant rates in defined pathogens 5 2Q2025 MoCCEE NACU 4.4.1 Establish monitor antimicrobial consumption 4.4.1.1 Guideline and plan developed for measuring antimicrobial consumption (regular surveillance and PPS) 2 (one for human and one for animal) 1Q2025 MTG-MFDA MoAAW & MoFOR (Agriculture, Aquaculture) QARD NACU 4.4 Antimicrobial consumption surveillance shall be established 4.3.3 Resistant pathogen testing in environment 4.4.1.2 Health professionals trained on antimicrobial consumption and PPS methodology Train minimum 2 sta� from each tertiary hospital 1Q2025 4.4.2 Reporting of Antimicrobial consumption 4.4.2.1 Reports on antimicrobial consumption generated (may choose priority areas like ICU/ medical/ward All Tertiary care hospitals Human once/ year Annually (from 2025) 39 medical ward/ OT/ surgical ward etc) continuous monitoring at least 3 monthly (preferred for tertiary care hospitals) or Point prevalence survey 80% of other human health facilities once by 2028 From 2025 50% of Animal farms Annually (from 2025) 4.4.2.2 Audit on OTC sales of antimicrobials from pharmacy 4 (Focused on islands with high population) Annually (from 2025) 4.5 Health Care associated Infections surveillance shall be strengthened 4.5.1 Training of health Professional on HAI surveillance (only in Human Health) 4.5.1.1 IPC teams from major hospitals trained on HAI surveillance 2 from each hospital 1Q2025 4.5.2 HAI surveillance reports generated 4.5.2.1 HAI surveillance reports generated 25% of hospitals 1Q2025 QARD NACU 4.6 Develop integrated one health surveillance system for AMR 4.6.1 Develop integrate the AMR surveillance with early warning system 4.6.1.1 Develop integrated surveillance framework and system 1 1Q2025 NACU/ MFDA QARD HPA MoAAW & MoFOR MOCCEE 40 For evidence- based decision making and policy amendments in place for alerts on AMR 4.5.1.1 IPC teams from major hospitals trained on HAI surveillance 1 41 4Q2026 Strategic Objec�ve 5: Hygiene, Infec�on Preven�on and Control (IPC) Infection prevention and control, especially in the context of hospitals, is an important aspect of a strategic plan to contain AMR since clinical settings represent an ecosystem of high antimicrobial usage. Within this ecosystem exists patients, who may be immunologically impaired. These patients not only represent the population that is vulnerable to serious life-threatening infections and at the same time, they promote the emergence of resistance. On the other hand, better hygiene (WASH) and Infection prevention control represent methods to cut down on the spread of infections in ambulatory human and animal care facilities, in food production systems and in the community in general. Vaccination in humans and animals and biosecurity in food production systems are specific interventions that if implemented effectively, can result in better health outcomes and reduced risk of emergence of AMR. The Situation Analysis of measures related to hygiene, infection prevention and control in human, animal and related sectors in Maldives reveals frameworks that have been developed. With regards to standardised guidelines, awareness, training and resources, the quality and scale of implementation has been less than optimal. Health Care Quality Standards are platforms that could be capitalised. Work has been done to develop and draft national standards and guidelines, such as the national drug policies, updated essential medicines lists and standard treatment guidelines. Though implementation has been poor, work has started on stewardship programme in healthcare settings or ambulatory settings, in human and animal health and food production sectors and HAI surveillance. Human vaccination programs are well-developed programs that will be further consolidated and animal vaccination strengthened. 42 Table 9: Objective 5- Reduce incidence of infection through effective sanitation, hygiene and infection prevention measures Strategy Objective 5: Reduce the incidence of infection through e�ective sanitation, hygiene and infection prevention measures Activiteis Performance indicator Target Time line Lead agency Implementing partners 5.1 Infection control and prevention practices shall be strengthened 5.1.1 Working group to evaluate existing IPC and HAI (human) guideline and finalize the data flow mechanism for HAI surveillance and submit for endorsement by NACC. For animal develop IPC guideline and endorse 5.1.1.1 Endorsement of IPC and HAI guideline 1 x human health 1Q2025 QARD (Human health) HPA with MOCCEE- WASH & waste NACU/ MFDA MoAAW & MoFOR (Agricu- lture & Acqua- culture) 1 x animal health 1Q2025 5.1.2 Healthcare institutions to adapt the national IPC guideline 5.1.2.1 No. of healthcare institutes have adapted the national IPC guideline 80% healthcare monitor via annually WHO tool 1Q2025 5.2.1 Constitute IPC committee healthcare facilities according to national IPC guideline 5.2.1.1 IPC committee in all health care facilities (human) IPC focal point in animal health 80% of tertiary hospitals 1Q2025 5.2.2.1 Centers with Infection control o�cer 80% of hospitals 1Q2025 5.2.2 Designated trained Infection Control O�cer at 5.2 Facility level IPC program 43 hospital levels (clinician and / microbiologist) 5.2.3 Designate trained Infection Control Nurses (ICN) at healthcare facilities (minimum 1 ICN/ 250 beds for tertiary care hospitals) 5.2.3.1 Centers with dedicated ICN 80% of hospitals 1Q2025 5.1 Monitor IPC related activities human and animal health 5.3.1 Monitor IPC program at health facilities (human and animal health). 5.3.1.1 Monitor IPC program facility level with WHO tool-human 100 % of hospitals and 80% of other health facilities Annually (start 2024) QARD MoAAW & MoFOR NACU/ MFDA 5.3.1.2 Monitor IPC program facility level animal health -get tool/develop 70% of animal health facility (start 2026) 44 5.2.3.2 Centres with designated ICN but not dedicated 80% of other health facilities Strategic Objec�ve 6: Op�mise and monitor Use of An�microbial Medicines 45 Use of antimicrobials in any form, even when rational and prudent, can precipitate resistance in target microbes. High antibiotic use may reflect over-prescription, easy access through over-the-counter sales, and more recently sales via the Internet which are widespread in many countries. The situation analysis reveals that Maldives has a fully functional National Regulatory Authority that is responsible for regulation and licensing; drug import and pharmacovigilance. Post licensing inspections including for retail pharmacies and OTC sales are carried out on national scale regularly. However, limited human and technical resources as well as the complex challenges of import-based system of procurement limit the effectiveness of regulatory activities. Import of AMAs used in food animal production sector including aquaculture is covered by the regulatory framework. The country lacks important instruments and systems such as a National AMR containment policy, AMU surveillance including surveillance of sales of antimicrobial agents. Animal health sector lags on all of the above fronts and is also constrained by lack of regulatory powers. Maldives will establish a robust system for regulation and surveillance of use of antimicrobial agents for control of use of antimicrobial substances in human, animal and food production sectors. Some of the measures taken will include an empowered National Drug Regulatory Authority, import frameworks favourable to regulatory requirements, update (with systemic efforts to ensure medications utilized in the country have verified GMP and GHP), the National AMR Containment and Use Policy and related regulatory frameworks, finalize the standard treatment guidelines with special reference to use of antimicrobial agents, Strengthening the National Antimicrobial Stewardship Programme and AMU monitoring programme in human and food animal production systems, ambulatory and community settings and including, residues testing in food products. Formal assessments will be carried out at the end of this period before nationwide scale up. The Strategic Plan to establish the above is as outlined below: Table 10: Objective 6- Optimize and monitor use of antimicrobial medicines Strategy Objec�ve 6: Op�mize and monitor use of an�microbial medicines Activiteis Performance indicator Target Time line Lead agency Implementing partners 6.1.1 Develop and revise antibiotic guideline for human use 6.1.1.1 antibiotic treatment guideline developed and revised for human use 1 1Q2025 QARD NACU 6.1.1.2 Antibiotic guideline app developed 1 1Q2025 QARD 6.1.2 Develop antibiotic guideline for animal use 6.1 Guidelines, protocols and clinical treatment pathways shall be developed/ updated for the management of infectious diseases to promote rational use of antimicrobials. 6.1.2.1 antibiotic guideline developed for animal health use 1 1Q2025 MoAAW & MoFOR 6.1.3 Revise the antibiotic stewardship guideline based on the antibiogram generated through laboratory surveillance 6.1.3.1 antibiotic stewardship guideline revised 1 1Q2025 MTG MFDA 6.1.4 Constitute the Antimicrobial Stewardship (AMS) committee or AMS team with defined TOR (to function under IPC committee or independently) to 6.1.4.1 AMS Team constituted with TOR 80% of hospitals 2Q2025 MTG-MFDA QARD 46 6.1.5 Stewardship teams active in the hospital 6.1.5.1 Antimicrobial restriction forms being utilized in the hospital with either a pre-authorization mechanism and/or post audit feedback mechanism for providers on prescribing patterns in place 90% of care hospitals 3Q2025 MTG-MFDA QARD 47 carry out stewardship functions in the hospital Strategic Objective 7: Develop the Economic Case for Sustainable Investments by taking into account the needs of the country regarding new Medicines, Diagnostic Tools, Vaccines, Research and Other interventions 48 The GAP AMR posits that the economic case should reflect the need for capacity building and training in low resource settings, while developing evidence-based interventions to reduce infections and combat AMR. The 2001 strategy for AMR containment could not achieve its goals; one of the reasons cited for the same is that there was absence of economic assessments, which evaluated the cost of doing nothing versus the cost/benefits of action at the present. The Situational Analysis in Maldives indicates that there is some prioritization of research on AMR by both policy makers and research community, though a proper research plan is not in place. Limited evidence exists on the nature and extent of AMR as a public health threat and drivers of AMR and AMU. This calls for policy and program relevant research to support planning and implementation of public health interventions. The phase of development of the health system provides an opportunity to put in place strategic research agenda for public health research and AMR in particular to inform health system responses. The Strategic Plan lays down a roadmap for establishing a strategic research agenda, with systematically prioritised research areas and knowledge gaps related to AMR that will feed into a national policy for research and innovation. According to NAP AMR multi-stakeholder platform and consortia will be established that will generate program and policy relevant evidence on and compare cost effectiveness of AMR control strategies. The strategic plan also envisions collaborations with national and international agencies, for implementation of strategic research agenda. This will be one of the key strategies for Maldives, given its existing nature of AMR threat and limited institutional capacity. Table 11: Objective 7- Develop the economic case for sustainable investment by taking into account the needs of the country regarding new medicines, diagnostic tools, research and other interventions Strategy Objective 7: Develop the economic case for sustainable investment by taking into account the needs of the country regarding new medicines, diagnostic tools, vaccines, research and other interventions Activiteis Performance indicator Target Time line Lead agency Implementing partners 7.1 Research on AMR shall be a priority and need-based research shall be promoted to generate evidence for clinical practice, rational use and support policy and planning. 7.1.1 Develop a research agenda for prioritization of AMR related areas 7.1.1.1 Research agenda developed 1 2Q2025 MFDA QARD HPA MoAAW & MoFOR (Agriculture and maniculture) MoCCEE MMA MNA Allied health Societies Relevant Universities Health institutes Livestock handlers Environmental agencies 7.1.2 Prioritize and conduct research in human health related to AMR 7.1.2.1 Human Health related AMR Study published 80% agenda Annually (from 2025) 7.1.3 Prioritize and conduct research in animal, food safety and environmental surveys related to AMR 7.1.3.1 Number of animals, food safety and environmental AMR related studies published 80% of research agenda Annually (from 2025) NACU with NACC research TSC 7.1.4 Collaborative research on AMR 7.1.4.1 Number of collaboration research conducted 80% of research agenda Annually (from 2025) 7.2 New innovation, ensure access and supply 7.2.1 Evaluate the needed new antibiotics or diagnostics for improved 7.2.1.1 Undertake a need assessment and develop a 1 1Q2025 NACU with NACC research TSC MFDA QARD HPA 49 50 antimicrobial utilization and infectious disease management processes. report for required antibiotics and new diagnostic technologies, vaccines plan MoAAW & MoFOR (Agriculture and maniculture) MoCCEE 7.2.2 Discuss needed vaccination for preventing AMR (adults and children) hold discussion with MTAGI 7.2.2.1 Meeting minutes of meeting with MTAGI 1 2Q2025 NACU/ MFDA with NACC research TSC NA= not applicable 51 Annex 1. SWOT analysis on AMR program implementa�on Annexure Helpful Harmful Strength Weaknesses Support available for critical health and environment related issues, such as pandemic response, WASH and waste management. Support for introduction o f n e w v a c c i n e s (COVID-19, PCV, Rota) Limited awareness of AMR, Surveillance and IPC at high level AMR committee established. Focal point in MFDA for AMR was available for some time and undertook AMR related activities and trainings. Committed sta in MoH but not dedicated to AMR National level poor leadership support, poor coordination mechanism and governance for AMR related activities. High level Multi-Sectoral Steering Committee (NMSC) for AMR not formed AMR c o o r d i n a t i o n u n i t n o t available with dedicated sta for coordinated activities National level budget available f o r c e r t a i n a c t i v i t i e s : immunizat ion , some IPC related activit ies, waste management. L a c k o f N a t i o n a l l e v e l dedicated budget for AMR related activities: awareness, education, survei l lance, Monitoring & evaluation, Research and Development. Infection control and link nurses available in many health facilities. Clinicians with knowledge of AMR available in many centres. National level I P C g u i d e l i n e s a n d S t e w a r d s h i p g u i d e l i n e avai lable. Some tert iary h o s p i t a l s h a v e t r a i n e d microbiologists and clinicians with knowledge of AMR IPC training conducted for various h e a l t h f a c i l i t i e s Global guidance documents and technical support available on AMR related issues and Limited trained sta in health care facilities in surveillance activities, high turnover of sta . Lack of knowledge on stewardship Inadequate AMR related lab knowledge Table 12: SWOT analysis on AMR program implementa�on Present factors Awareness and political will Coordination and stakeholder engagement Financial resources Technical capacity 52 IPC related activities: MoH QA dedicated unit/focal point available? IPC committees established in some health facilities. Immunization related activities: MTAGI and dedicated unit in HPA available D e d i c a t e d u n i t / h u m a n resource for coordination of AMR related activities at national level not available Poor coordination with other already existing programs: TB, IPC, immunization, WASH Limited number of quality microbiology labs Private animal sector not on board National AMR committee and technical subcommittees formed and few meetings c o n d u c t e d Training for AMR and GLASS reporting undertaken Limited trained dedicated sta at national level and facility level for AMR related activities, Implementation of NAP AMR activities Few tertiary level hospitals in process of collecting AMR related data. Antimicrobial import being monitored at national level Poor reporting of HAI, AMR data to national level and international platforms (GLASS) Poor monitoring of rational use of antimicrobials. Lack of national level, regular and adequate, measurable outcome or process indicators of NAP Monitoring and Data Opportunities Threats Future factors Awareness and political will Establish AMR governance structures and generate a w a r e n e s s o n A M C surveillance at the highest political level through advocacy Sustaining high level political commitment & support during unstable political periods and change of high-level posts. Establish AMR governance structures and coordination mechanism with national level AMR coordination unit, National level human health AMR and Animal health AMR focal point, and improve coordination with establ ished national level programs Involve private sector in AMR activities High turnover of sta at di erent levels and lack of adequate replacements. Sta may get diverted for other work ( p a n d e m i c r e s p o n s e / outbreaks etc) Coordination and stakeholder engagement Structures or enablers for implementation 53 Donor funds can be made available for AMR related activities Identify internal donor fund streaming / better integration of AMR related issues into existing programs Limited duration of availability of donor funds Financial resources C o n d u c t t r a i n i n g a n d awareness on AMR (IPC, antimicrobial stewardship, animal health, aquatic animal health, food safety etc.) Integrate HAI surveillance with AMR reporting using Infection control nurses and link nurses in health facilities. Each health facility to have an infection control o cer (clinician or microbiologist) responsible for A M R a n d a n t i m i c r o b i a l stewardship. Sustaining of IPC and AMR related activities as trained sta maybe allocated for other tasks: (pandemic preparedness, Quality related activities etc). High turnover of trained sta Technical capacity Animal health establish national focal point (vet), include IPC, H A I a n d s t e w a r d s h i p component in animal health. Reporting of outbreaks in veterinary facilities etc. Assess laboratory capacity / integrate and support for laboratory component of animal AMR r e l a t e d s u r v e i l l a n c e / F o o d s a f e t y : e s t a b l i s h antimicrobial residue testing Establish well defined AMR governance structure, with dedicated unit for coordination of AMR related activities and annual plan Sustainability and high human turn over Structures or enablers for implementation 54 Establish well defined AMR governance structure, with dedicated unit for coordination of AMR related activities and annual plan Identify champions at di erent levels (political, councils, social media, religious etc). TOTs for AMR related education and training (could be the ICN or Infection control O cer at health facility level) Competing interest from private sector on reporting such as outbreaks etc. Implementation of NAP AMR activities Use surveil lance data for standard of care and economic case for implementing AMR activities S t r e n g t h e n m o n i t o r i n g i n d i c a t o r s (p r o c e s s a n d outcome based) for measuring NAP implementation and use for advocacy Limited data (monitoring and surveillance) shared within and in-between sectors may lead to inconsistent messaging on AMR Monitoring and Data 55 2 2 2 Exploratory and adoption Program installation Initial implementation Full operation demonstrated Sustainable operation 1 2 3 4 5 Annex 2. Situa�on analysis of NAPAMR 2017 to 2022 implementa�on Table 13: Situa�on Analysis of NAP AMR 2017-2022 implementa�on 1. Awareness Strategic Objective Planned Strategic intervention Conduct KAP Studies on AMR, AMU,(human and animal ) environmental rela�onships in different target groups (school students and teachers, general public, policy makers, clinicians, pharmacists, nursing staff, farmers in poultry/ goat/aquaculture farming, pet owners and pet shop owners) StatusSub-Activities 1 . 1 : To i m p ro ve awareness of AMR amongst the general p u b l i c a n d professionals Target 2017 Design evidence-based communica�on campaigns with accurate and relevant messages targe�ng priority groups 2018 Roll out communica�on campaigns on AMR 2017-2018 Incorporate AMR and related topics in school grade 1-12 school curricula. Limited scale tes�ng of revised curriculum along with regular audit of courses will be conducted before planning a na�onwide scale up by 2022 2019 3 Evaluate communica�on campaigns followed by na�onwide implementa�on. Pilot campaigns will be evaluated in 2019. This will be followed by na�onwide scale up and scale out of awareness campaigns in 2019 with regular monitoring and evalua�on 2 1 . 2 I m p r o v e knowledge of AMR and related topics in professionals through p r o f e s s i o n a l e d u c a � o n a n d training deployed at na�onal scale Conduct KAP Studies to assess gaps in knowledge on AMR, hygiene & IPC, environmental rela�onships in professional groups 2017-2018 2 Revise and roll out professional development courses of human and animal health, the food industry and agriculture sectors to include topics on AMR and related issues. Roll out of courses will be done on a limited scale along with concurrent regular audits followed by na�onwide scale up. 2019-2020 1 Revise undergraduate and postgraduate curricula in human and animal health, Food industry and Agriculture sector to include topics on AMR and related issues. Limited scale tes�ng of revised curriculum along with regular audit of courses will be conducted before planning a na�onwide scale up in next phase of NAP 12020-2022 Strategic Objective Planned Strategic intervention StatusSub-Activities Target 2. Surveillance of AMR 2.1 Establish a na�onal coordina�on structure for surveillance of AMR Establish AMR Surveillance Coordina�on Unit, define mandates, terms of reference and iden�fy a focal point. The ASCU will be located in the MFDA 2017 1 Develop a One Health AMR guidelines and plan for surveillance in humans, animal and food industry based on interna�onal standards and guidelines 12017-2018 Enlist priority pathogens and an�microbials for surveillance in human, animal and food industry 2017-2018 3 Assess and inventory of resources for sen�nel environmental surveillance (ASCU with EPA and Ministry of Environment) Conduct trainings on AMR surveillance for surveillance staff 1 1 Develop an integrated human and animal IT pla�orm for AMR surveillance repor�ng. WHONET pla�orm will be implemented for epidemiological and laboratory AMR surveillance data entry, storage and transmission in human clinical and food tes�ng labs 1 Implement Na�onal AMR Surveillance Program including sen�nel environmental surveillance of an�microbial resistance organisms and an�microbial residues. IGMH, Regional Hospitals and Atoll Hospitals with exis�ng Bacterial AST facility will be targeted in the pilot phase. Addi�onally, ADK Hospital from private sector will be included as a surveillance site. For animal surveillance selected poultry commercial, goat farms and aquaculture farms will be recruited and specimens submi�ed to NHL 2019-2022 2 Establish formal linkage of Na�onal AMR Surveillance Programme and WHO GLASS 2021-2022 2 Conduct formal assessment of Na�onal AMR Surveillance Program 1 2.2: Build laboratory capacity under the l e a d e r s h i p o f a Na�onal Referral Laboratory (NRL) to produce high-quality microbiological data f o r p a � e n t a n d f o o d - s a f e t y management and support surveillance ac�vi�es. Iden�fy Na�onal Reference Laboratory (NRL) for AMR Surveillance in Maldives with exper�se in methods for confirming and characterising specific pathogens, performing suscep�bility tes�ng, organising quality assurance and par�cipa�ng in external quality assurance schemes (EQARDS). The Microbiology Laboratory at IGMH will be iden�fied as NRL. 2 Iden�fy par�cipa�ng laboratories of Na�onal AMR Surveillance Network that are capable of iden�fying target pathogens and perform suscep�bility tes�ng (centres as per sec�on 2.1) 2 2.3 Develop a mul�- centric surveillance system on the na�onal scale to provide early warning of emerging r e s i s t a n c e a n d monitoring of secular trends at na�onal and sub-na�onal levels. Establish a network of agencies for AMR hazard and risk assessment 12017-2019 Strategic Objective Planned Strategic intervention StatusSub-Activities Target Develop and disseminate guidelines and na�onal standards for systema�c collec�on, sharing, and assessment of AMR hazard events 1 Conduct surveys to establish baseline es�mates and trends of AMR to determine risks and establish thresholds for alerts and ac�on systems Enlist priority pathogens and AMAs for AMR hazard risk assessment 2 1 Establish a central library or database on AMR risk informa�on 22020-2021 Conduct and communicate comprehensive real �me analysis of AMR hazards in the human, animal, food industry and environment sector to inform programme planning and ac�on 2021-2022 1 3. Hygiene, Infec�on Preven�on and Control (IPC) 3.1: To establish a na�onal infec�on preven�on and control programme through full implementa�on and compliance Develop IPC guidelines with implementa�on for infec�on preven�on and control in all health care se�ngs (hospital and ambulatory) in human sector; IPC/biosecurity in animal health facili�es (hospital and ambulatory), vaccina�on, and biosecurity in the farm to fork chain Evaluate exis�ng IPC, and Biosecurity guidelines. Develop a na�onal IPC policy, manda�ng the crea�on and harmoniza�on of Na�onal IPC Programmes in healthcare facili�es and food produc�on systems (poultry, goat farms, aquaculture) 2 2 with the IPC guidelines within c Iden�fy target groups to be trained in IPC from different sectors and at different levels 2 Train target groups in different sectors in IP Roll out IPC program in human health, animal health and food industry Review exis�ng professional curricula for content on IPC and develop training modules for their incorpora�on into professional courses Assess Na�onal IPC Programme and recommend Na�onwide scale up in human, animal healthcare facili�es, food produc�on systems. 2 2 2 2 3.2: Decrease Hospital Acquired Infec�on (HAI) and associated AMR (Human Health) Develop guidelines for Hospital Associated Infec�on (HAI) Surveillance 2022 2019-2020 2017-2018 2019-2022 Implement a pilot scale on HAI surveillance in select public and private healthcare facili�es 3 3 Integrate HAI surveillance network into Na�onal AMR surveillance network; Conduct formal assessment of HAI Surveillance network for na�onwide scale-up 2022 1 3.3: To limit the development and spread of AMR outside health se�ngs Review and evaluate the exis�ng na�onal campaigns on water, sanita�on & hygiene (WASH), food safety, and vaccina�on in humans and animals Implement formal campaigns for sanita�on and hygiene in human, animal, food animal produc�on sector 2017 2018 2 2 3 Human 2 2 2 2 2 3 Strategic Objective Planned Strategic intervention StatusSub-Activities Target 1 Animal Evaluate exis�ng vaccina�on programme in human and animal sectors for their effec�veness and coverage Review and revise undergraduate and post graduate curricula to include course content related to water, sanita�on, hygiene and food handling prac�ces 2018-2019 Evaluate campaigns on hygiene and sanita�on 2019 4: Op�mise Use of An�microbial Medicines 4.1: Establish a na�onal An�microbial Stewardship Programme on a na�onal scale to improve and measure the appropriate use of an�microbials Develop a na�onal AMR containment policy and organiza�onal framework within the charter of the Policy 2017-2019 Formulate a regulatory framework for control of an�microbial substances in human, animal sectors and food industry Develop standard treatment guidelines (STGs) for an�microbial use in human and animal healthcare and food industry Conduct surveys to characterize ins�tu�onal An�microbial Stewardship Programmes (AMSP) Develop evidence-based guidelines for a Na�onal AMSP Implement AMR containment policy for control of human and veterinary use of an�microbial substances in human and animal health care, ambulatory and community se�ngs and food industry 4.2: Regulate post-marke�ng quality of drugs to ensure access to safe and quality an�bio�cs 3 2 Formulate a Na�onal Drug Policy with special reference to AMAs and AMR applicable to human, animal health, and food industry. Introduce legisla�on and regula�ons on AMAs for veterinary use. Strengthen exis�ng Na�onal Drug Regulatory Authority and establish addi�onal regulatory frameworks. Human resource and technical capacity of Na�onal Health Laboratory of MFDA will be strengthened to establish systema�c surveillance of quality of imported drugs and food at points of entry 2018-2022 2017 2017-2019 2 3 as well as post marke�ng surveillance of drugs and food. MFDA will cover drugs used in human health, extend similar regulatory framework to import medicines for animal health, aquaculture and food produc�on Establish import procurement systems favourable to regulatory compliance Establish a system for the coordina�on and colla�on of data on drug quality Establish and implement an ins�tu�onal network with the capacity for quality control and enforcement of regulatory provisions for an�microbial agents or APIs Conduct independent periodic surveys to es�mate the extent of OTC and inappropriate sales of an�bio�cs and APIs 1 1 3 3 22017 -2022 Strategic Objective Planned Strategic intervention StatusSub-Activities Target 4.3: Establish mechanisms to monitor an�microbial usage on a na�onal scale to inform interven�ons to reduce overuse and promote prudent use of an�microbial substances Establish AMU Surveillance coordina�on structure Design an AMU and residue monitoring program in humans, animals and food industry; develop guidelines to implement residue tes�ng Implement AMU surveillance and residue tes�ng Conduct integrated analysis of AMU, AMR and residue surveillance data to guide programme planning 2017 2018 2019-2022 1 2 AMU humans only 2 AMU only 2 AMU only 5: (Economic) Case For Sustainable Investments And Increase Investments In New Medicines, Diagnos�c Tools, Vaccines And Other Interven�ons To Reduce An�microbial Use To promote sustainable investment in new medicines, diagnos�c tools, vaccines and other interven�ons by developing a strategic research agenda and na�onal research policy Create an inventory of relevant networks, ini�a�ves, ins�tu�ons and experts involved in AMR research Develop a Strategic research agenda, with systema�cally priori�sed research areas and knowledge gaps in the field of AMR Develop a Na�onal AMR Research Policy Establish a mul�-stakeholder pla�orm to guide AMR research and innova�on Document and disseminate to different stakeholders, evidence on AMR and related issues for policy and programme interven�on 2 1 1 1 12020-2022 2018-2019 2017-2018 2017-2018 NAP AMR governance Summary of mul�sector indicators Sectors involved in AMR mul�sector coordina�on Formulated mul�sector coordina�on mechanism Developed NAP AMR Implemen�ng NAP AMR Country in the process of revising NAP AMR or developing new one Country has a monitoring and evalua�on plan for AMR Country has government supported na�onwide awareness campaigns Country has established or started the implementa�on of an integrated surveillance system for AMR NO NO NO NO YES YES YES Human health Terrestrial animal health Aqua�c animal heath Plant health Food produc�on Food safety Environment YES YES YES YES YES NO NO Table 14: Tripar�te AMR Country Self assessment Survey 2022 Maldives (TrACSS)- AMR governance component Annex 3. Tripar�te AMR Country Self-Assessment Survey 2022 Maldives (TrACSS)- AMR governance component Annex 4: Facility level data collec�on tool for IPC and An�microbial Stewardship Program (AMSP) Assessment on Facility level (Infection Prevention and Control (IPC) and Antimicrobial Stewardship (AMS) program (World Health 2018, World Health Organization 2018, Purva, Randeep et al. 2019) Name of the healthcare facility: Total inpa�ent bed number Services provided by the facility: OPD IPD Surgical Day care (dialysis etc): Date of filling the assessment form: dd /mm /year Staff who took part in filling the form (Put the main responsible person as number one) 1 2 3 4 Name Designa�on Job role comment Known published studies on IPC, HAI or AMR from the facility and/from Maldives. Please provide link below 1. 2. 3. 4. PART 1: FACILITY LEVEL IPC PROGRAM Table 15: Facility level IPC program assessment tool (adapted from WHO) PART 2: FACILITY LEVEL AMS PROGRAM Assessment of Antimicrobial Stewardship Program (AMSP) activities in the facility Established at facility ✔ x Comment Leadership support Does your facility have a formal, written s t a t e m e n t o f s u p p o r t f r o m f a c i l i t y administration that supports e�orts to improve antibiotic use (antibiotic stewardship)? Accountability Does your facility receive any budgeted financial support for antibiotic stewardship activities (e.g., support for salary, training, or IT support)? Is a sta� member directly responsible for coordination and program outcomes of stewardship activities at your facility? Does your institution have a committee to review processes and outcomes of the stewardship program? Does your antibiotic stewardship committee meet at least once every 6 months? Are the minutes of the stewardship committee communicated to all stakeholders? Key support for the antibiotic stewardship program Does any of the sta� below participate in the stewardship program to improve antibiotic use? Tick as appropriate ·Clinical pharmacist or other pharmacy staff ·Clinical pharmacologist or pharmacology staff ·ID physician (specialists in medicine, paediatrics and surgery who deal with per�nent infec�ons) ·Q u a l i t y i m p r o v e m e n t s t a ff ·C l i n i c a l m i c r o b i o l o g i s t ·IT department staff (not on commi�ee but they help us as needed) ·Clinical departments heads (not heads, but members. All the proceedings are communicated to the heads and they preside over the mee�ng when any of their units are being audited) ·Hospital administra�on staff Table 16: Facility level AMS program assessment tool ·Infection prevention and control team/focal persons Assessment of Antimicrobial Stewardship Program (AMSP) activities in the facility Established at facility ✔ x Comment Policies to support optimal antibiotic use Does your facility have a policy that requires p r e s c r i b e r s ? Does your facility have a policy that requires prescribers to document in the medical record a dose and duration for all antibiotic prescriptions? Does your facility have a policy that requires prescribers to document in the medical record an indication for each antibiotic prescription? Does your facility have a policy that requires prescribers to collect and submit relevant clinical specimens before an antibiotic is prescribed? Does your facility have a policy that requires prescribers to list the prescribed antibiotic by its g e n e r i c n a m e ( i n s t e a d o f b r a n d n a m e ) Policies to support optimal antibiotic procurement Does your facility have a policy that requires the pharmacy to maintain a facility-level antibiotic formulary (i.e., a list of the antibiotics that the institution will procure and stock) Does your facility have a policy that requires the pharmacy to avoid procurement of unnecessary or duplicative combinations of antibiotics? (e.g., cloxacillin and dicloxacillin) Broad interventions to improve antibiotic use Are the following actions to improve antibiotic prescribing conducted in your facility? Is there a procedure for reviewing the appropriateness of all empiric antibiotics 48 h after the initial orders? Do specified antibiotic agents (e.g., colistin, carbapenems) need to be approved by a senior physician, pharmacologist, or ID specialist prior to administration (i.e., pre-authorization) at your facility? D o e s a p h y s i c i a n , p h a r m a c i s t , o r pharmacologist conduct retrospective audit with feedback for courses of therapy for specified antibiotic agents (e.g., colistin, carbapenems) at your facility Assessment of Antimicrobial Stewardship Program (AMSP) activities in the facility Established at facility ✔ x Comment Prescription- specific interventions to improve antibiotic use ·Does your facility have wri�en guidelines or policies f o r t h e f o l l o w i n g a c � o n s ? ·Recommended changes from intravenous to oral an�bio�c therapy in appropriate situa�ons (e.g., switch to an appropriate an�bio�c with good oral bioavailability such as a quinolone in the se�ng o f c l i n i c a l i m p r o v e m e n t ) ? ·Dose adjustments in cases of organ dysfunc�on? ·D o s e o p � m i z a � o n ( p h a r m a c o k i n e � c s / pharmacodynamics) for treatment of organisms with r e d u c e d s u s c e p � b i l i t y ? ·Feedback in situa�ons where therapy might be unnecessarily duplica�ve (e.g., double anaerobic c o v e r a g e ) ? ·Time-sensi�ve stop orders for specified an�bio�cs (e.g., colis�n, carbapenems, surgical prophylaxis to be stopped a�er a certa in number of days)? Does your facility provide wri�en guidance for treatment of the following common infec�ons? Diagnosis and infections specific interventions to improve antibiotic use Does your facility provide written guidance for treatment of the following common infections? Diagnosis and infections specific interventions to improve antibiotic use – hospitalised patients C o m m u n i t y - a c q u i r e d p n e u m o n i a H e a l t h c a r e - a s s o c i a t e d p n e u m o n i a Community-acquired urinary tract infection Healthcare-associated urinary tract infection Skin- and soft-tissue infections (e.g., abscess, cellulitis) Surgical prophylaxis Acute gastrointes�nal infec�ons Meningi�s Neonatal sepsis Clinical sepsis (non-neonates) Assessment of Antimicrobial Stewardship Program (AMSP) activities in the facility Established at facility ✔ x Comment Maternal intrapartum/postpartum infections Diagnosis and infections specific interventions to improve antibiotic use – outpatients Upper respiratory tract infection CAP Skin- and soft-tissue infections Acute gastroenteritis Sexually transmitted infections Maternal antenatal/intrapartum/postpartum infections P r o c e s s measures R o u t i n e m o n i t o r i n g a l l o w s p r o g r a m coordinators to assess the performance of stewardship practices at specified intervals (Does your stewardship programme routinely monitor adherence to... ...documentation of dose in inpatient antibiotic p r e s c r i p t i o n s ? . . .documentation of duration in inpatient a n t i b i o t i c p r e s c r i p t i o n s ? . . .documentation of c l inical indication in i n p a t i e n t a n t i b i o t i c p r e s c r i p t i o n s ? . . . f a c i l i t y - s p e c i fi c e m p i r i c t r e a t m e n t recommendations for at least one common i n p a t i e n t i n f e c t i o n ( i n f e c t i o n s l i s t e d i n S e c t i o n H ) ? ...collecting and submitting cultures before beg inning empiric ant i biot ic therapy for i n p a t i e n t i n f e c t i o n s ? ...adjusting antibiotics based on culture results f o r i n p a t i e n t i n f e c t i o n s ? . . . d o c u m e n t a t i o n o f d o s e i n o u t p a t i e n t a n t i b i o t i c p r e s c r i p t i o n s ? ...documentation of duration in outpatient a n t i b i o t i c p r e s c r i p t i o n s ? . . .documentation of c l inical indication in o u t p a t i e n t a n t i b i o t i c p r e s c r i p t i o n s ? . . . f a c i l i t y - s p e c i fi c e m p i r i c t r e a t m e n t recommendations for at least one common outpatient infection (infections listed in Section H)? Assessment of Antimicrobial Stewardship Program (AMSP) activities in the facility Established at facility ✔ x Comment ...collecting and submitting cultures before beg inning empiric antibiotic therapy for o u t p a t i e n t i n f e c t i o n s ? ...adjusting antibiotics based on culture results for outpatient infections Antibiotic use and outcome measures Does your facility track rates of infections caused by antibiotic resistant pathogens (e.g., bloodstream infections caused by carbapenem-resistant Enterobacteriaceae or colistin-resistant Gram-negative bacteria)? Does your faci l ity produce an annual cumulative antibiogram for at least one common infection ( infections l isted in S e c t i o n H ) ? Does your facility monitor antibiotic use (consumption) at the unit level and/or facility-wide level by one of the following m e t r i c s : By counts of antibiotics administered to p a t i e n t s p e r d a y ( d a y s o f t h e r a p y ) ? By number of grams of antibiotics used (DDD)? By overall purchasing cost of antibiotics consumed Reporting information to sta� on antibiotic use and resistance Does your stewardship programme share unit- /department-specific reports on antibiotic use w i t h p r e s c r i b e r s ? Has a current antibiogram for common infections been disseminated to prescribers at y o u r f a c i l i t y i n t h e p a s t y e a r ? Do prescribers routinely receive direct, personalised communication about how they can improve their antibiotic prescribing (e.g., dose adjustments, narrowing antibiotics b a s e d o n c u l t u r e r e s u l t s ) ? Do prescribers receive warnings regarding clinically significant interactions between prescribed antibiotics and other medications (e.g., co-trimoxazole and phenytoin toxicity, ototoxicity induced by gentamicin in combination with loop diuretics Assessment of Antimicrobial Stewardship Program (AMSP) activities in the facility Established at facility ✔ x Comment Education Does your stewardship program provide orientation to prescribers for facility-specific a n t i b i o t i c p o l i c i e s ? Does your stewardship program provide refresher training to prescribers for facility- s p e c i fi c a n t i b i o t i c p o l i c i e s ? Does your stewardship programme provide unit-/department-specific training on antibiotic policies ID: Infectious disease, CAP: Community-acquired pneumonia, IT: Information technology, DDD: Defined daily dose References Australian Government (2015). "Responding to the threat of antimicrobial resistance: Australia's First National Antimicrobial Resistance Strategy 2015–2019." from http://www.health.gov.au/internet/main/publishing.nsf/Content/1803C433C71415CAC A257C8400121B1F/$File/amr-strategy-2015-2019.pdf HM Government (2019). Contained and controlled: The UK's 20-year vision for antimicrobial resistance, Global and Public Health Group, Emergency Preparedness and Health Protection Policy Directorate. HM Government (2019). Tackling antimicrobial resistance 2019–2024: The UK's five-year national action plan. . D. o. H. a. S. care. London, Global and Public Health Group, Emergency Preparedness and Health Protection Policy Directorate. Murray, C. J., et al. (2022). "Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis." The lancet 399(10325): 629-655. Pattis, I., et al. (2022). "Antimicrobial Resistance in New Zealand—A One Health Perspective." Antibiotics 11(6): 778 Purva, M., et al. (2019). "Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: report from a multicentric initiative of global health security agenda. “ Indian journal of medical microbiology 37(3): 309-317. World Bank (2017). Drug-resistant infections: a threat to our economic future, Washington, DC: World Bank. World Health, O. (2018). Improving infection prevention and control at the health facility: Interim practical manual supporting implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes. Geneva: World Health Organization; 2018 (WHO/HIS/SDS/2018.10). Licence: CC BY-NC-SA 3. 0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps. who. int/iris. . World Health Organization (2015). Global action plan on antimicrobial resistance. Geneva, World Health Organization. World Health Organization (2018). Infection prevention and control assessment framework at the facility level, World Health Organization. http://www.health.gov.au/internet/main/publishing.nsf/Content/1803C433C71415CACA257C8400121B1F/$File/amr-strategy-2015-2019.pdf http://www.health.gov.au/internet/main/publishing.nsf/Content/1803C433C71415CACA257C8400121B1F/$File/amr-strategy-2015-2019.pdf http://apps http://apps World Health Organization (2019). Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018: an update on two years implementation of national action plans. Regional O�ce for South-East, Asia, New Delhi, World Health Organization,. World Health Organization (2021). "Antimicrobial resistance and the United Nations sustainable development cooperation framework: guidance for United Nations country teams.” World Health Organization (2021). "Tripartite and UNEP support OHHLEP's definition of "One Health": Joint Tripartite (FAO, OIE, WHO) and UNEP Statement." 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