National Action Plan on Antimicrobial Resistance (AMR) 2019 - 2023

Papua New Guinea National Action Plan on Antimicrobial Resistance i Foreword Antimicrobial medicines have been the cornerstone of basic and modern medicine for decades and have been used effectively to treat and prevent infections in humans and animals since the first discovery of penicillin by Alexander Fleming in 1928. After the first discovery of penicillins, other antimicrobials were discovered and used widely in the treatment of various infections in humans and animals. Over decades - these antimicrobials were used inappropriately resulting in the development and spread of resistance. The antimicrobial resistance phenomenon was predicted years ago in 1945 by Alexander Fleming himself while receiving his Nobel Prize for the discovery of penicillin. In fact this prediction was confirmed five years before that speech. Today, Antimicrobial Resistance (AMR) poses a significant national and global threat to human and animal health. If no action is taken, antimicrobial resistance has the potential to reverse all gains made in modern medicine and seriously put the lives of people and animals at risk of dying, from infections that were once treatable. This situation is alarming given that current pipeline for newer antimicrobials is drying up. In response to this looming crisis, the World Health Assembly (WHA) in May 2015, adopted a Global Action Plan on Antimicrobial resistance, and urged member states to develop their own national action plans. Papua New Guinea (PNG) started discussions in 2015 and hosted two consultative workshops in 2016 and 2017 where relevant stakeholders from health, agriculture and environment were engaged to provide direction, concluding in the development of the PNG Country Action Plan on Antimicrobial Resistance 2019 – 2023. This is a multi-stakeholder plan, involving the health, agriculture and environment sectors that are impacted directly by this emerging crisis. Better implementation will require closer cooperation by adopting the ‘One Health’ approach as a guiding principle for working together on AMR. It is the first National Action Plan on AMR developed for the Country to address the AMR crisis for the period until 2023. It includes a Multi-Sectoral Governance Framework and an Operational Plan with activities tied to 5 Strategic Objectives as per the WHO Policy Package on AMR. Implementing Government Agencies and partners should proactively adopt the Operational Plan and fund activities appropriately to move this important agenda forward. We, the Secretaries of Health (NDoH), Agriculture and Livestock (DAL) and Managing Directors of Conservation and Environment Protection Authority (CEPA) and National Agriculture Quarantine & Inspection Authority (NAQIA) commit to take full ownership of this Plan. We understand the potential threat of AMR to the health and security of our Country and its potential impact on the achievement of the PNG Vision 2050. It is our hope that the Country actions implemented through this Plan will contribute meaningfully to national and global efforts to reduce the spread of antimicrobial resistance and ensure PNG continues to benefit from the use of available antimicrobials for a long time yet. Papua New Guinea National Action Plan on Antimicrobial Resistance ii We, hereby, pledge to commit necessary resources and to ensure our Agencies and our partners work together to implement this Plan and address this growing health and security threat. Papua New Guinea National Action Plan on Antimicrobial Resistance iii Acronyms and abbreviations AAHL Australian Animal Health Laboratory AMR Antimicrobial Resistance AST Antimicrobial Sensitivity Testing CDC Centres for Disease Control CEPA Conservation and Environment Protection Authority CPHL Central Public Health Laboratory CSA Country Situation Analysis DAL Department of Agriculture and Livestock DFAT Department of Foreign Affairs & Trade FAO Food and Agriculture Organisation GDP Gross Domestic Product HIV Human Immunodeficiency Virus IPC Infection Program Control JICA Japanese International Cooperation Agency M&E Monitoring and Evaluation MDR Multi-drug Resistance MSF Medicines Sans Frontier NAMRSC National Antimicrobial Resistance Steering Committee NAQIA National Agriculture Quarantine & Inspection Authority NDoH National Department of Health NGO Non-government Organisations NTP National Tuberculosis Program OIE World Organisation for Animal Health PMGH Port Moresby General Hospital PNG Papua New Guinea PNGIMR Papua New Guinea Institute of Medical Research PSSB Pharmaceutical Services Standards Branch SDG Sustainable Development Goal TB Tuberculosis TWG Technical Working Group UN United Nations UPNG University of Papua New Guinea USAID United States Agency for International Development WAAW World Antibiotic Awareness Week WHO World Health Organization XDR Extensive Drug Resistance Papua New Guinea National Action Plan on Antimicrobial Resistance iv Contents Foreword .................................................................................................................................... i Acronyms and abbreviations .................................................................................................... iii 1. Introduction ........................................................................................................................... 1 2. Country Situational Analysis on AMR .................................................................................. 3 2.1 Findings of the Country Situation Analysis on AMR ............................................... 3 2.2 Current State of Antimicrobial Resistance (AMR) in Papua New Guinea................ 4 2.2.1 Human Health ........................................................................................................... 4 2.2.2 Animal Health .......................................................................................................... 6 3. Multi-Sectoral Governance on AMR .................................................................................... 7 3.1 National AMR Steering Committee .......................................................................... 7 3.2 AMR secretariat......................................................................................................... 8 3.3 Technical Working Groups ....................................................................................... 9 4. Papua New Guinea National Action Plan on Antimicrobial Resistance (AMR) – One Health Approach ...................................................................................................................... 10 4.1 Strategic Objectives ....................................................................................................... 10 Objective 1: Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance ...................................................................................... 10 Objective 2. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training ............................................................ 10 Objective 3. Strengthen surveillance, diagnostic capacity and research on .................... 10 Objective 4. Strengthen sanitation, hygiene and infection prevention and control across all sectors ......................................................................................................................... 11 Objective 5. Strengthen appropriate access and optimize the use of antimicrobial medicines in all sectors .................................................................................................... 11 5. Implementation, Monitoring and Evaluation ....................................................................... 12 6. Operational Plan (4 Years: 2019-2023) ............................................................................... 13 Glossary ................................................................................................................................... 27 Contributors ............................................................................................................................. 28 References ............................................................................................................................... 29 Papua New Guinea National Action Plan on Antimicrobial Resistance 1 1. Introduction Antimicrobial resistance (AMR) poses a profound threat to health and society. It has recently been recognized as a global health security risk that threatens the achievements of modern medicine and the Sustainable Development Goals (SDGs). AMR is considered as one of the biggest global health threats of our time. It poses a major challenge to health, food security, and development. It can affect anyone, of any age, in any country. Antimicrobial resistance happens when microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarial, and anthelmintic). Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”. As a result of AMR, medicines become ineffective and infections persist in the body, increasing the risk of spread to others. In response to this threat, the World Health Organization (WHO) developed the Global Strategy on AMR in 2001, and on the World Health Day 2011, the Organization launched a six-point policy package outlining actions governments need to take to combat AMR and to change the approach of all stakeholders. Additional discussions within WHO led the Organization to propose Country Situation Analysis (CSA) on AMR as a priority action to inform the development and implementation of national action plans. The Papua New Guinea Medicines Policy 2014, recognizes AMR as a threat and proposes to adopt global measures to mitigate the emergence of resistance to AMR. In 2015, the Global Action Plan on Antimicrobial Resistance, endorsed at the Sixty-eighth session of the World Health Assembly, called member states to complete their national action plans on AMR by May 2017. Papua New Guinea (PNG) conducted a Country Situation Analysis (CSA) on Antimicrobial Resistance (AMR) in 2016 with technical assistance from the WHO Country Office. As a result of the CSA, antimicrobial resistance has now been placed as a high priority agenda of the Ministries of Health, Agriculture and Environment. The CSA in general revealed that the current level of activities addressing AMR in PNG across the six elements outlined in the WHO Policy Package on AMR is low. The most significant challenge relates to rational use of medicines in humans and animals. The findings from the CSA were used to inform the development of the National Action Plan on Antimicrobial Resistance 2019 – 2023 which is organized under The WHO policy package on AMR and involves: o National coordination mechanisms; o Surveillance and laboratory capacity; o Access to, and quality of, essential medicines; o Rational use of medicines in humans and animals; o Infection prevention and control; and o Research and development Papua New Guinea faces significant challenges with systems of government and capacity. Although some mechanisms are in place to monitor, collect information and respond to the threat of AMR, generally, the systems need improvement and support to better deal with the AMR issue in the country. Papua New Guinea National Action Plan on Antimicrobial Resistance 2 The involvement of three major government ministries including health, agriculture and environment in AMR also requires better working relationships to be developed and maintained to allow coordinated implementation of AMR strategies and actions in the country. The One Health approach is the key guiding principle for working together on AMR. It recognizes that the health of the people is connected to the health of animals and the environment and therefore requires cooperation by all government stakeholders. The strategies and activities included in the Operational Plan resulted from discussions between AMR stakeholders during the consultation workshops in 2016 and 2017. The activities are for implementation by the government agencies concerned and their partners. Some activities are policy level while others are practical; for example, awareness campaigns for raising the profile of AMR in the country. The coordination of implementation and monitoring of AMR activities in the Operational Plan in Papua New Guinea will be based on the Multi-sectoral Governance Structure outlined in Section 3 of this Plan. There is a huge challenge for action on AMR to be taken at the national level in order to contribute meaningfully to the global response. PNG realizes this as a matter of national importance and hopes that this Plan will set the platform for action on AMR in the country. Papua New Guinea National Action Plan on Antimicrobial Resistance 3 2. Country Situational Analysis on AMR 2.1 Findings of the Country Situation Analysis on AMR Papua New Guinea is a lower-middle-income country located in the Western Pacific Region, one of the six regions of the World Health Organization. In 2015, the population of Papua New Guinea was projected to be 7 619 320, and in 2014 the Gross Domestic Product (GDP) per capita (at current US$) was estimated at US$ 2 268. A total of 40% of the population is under 15 years of age, and 4% is over 60 years of age. The urban population currently stands at 12% of the total population. The adult literacy rate for the population over 15 years is 60%. Communicable diseases continue to be the major cause of morbidity and mortality, with malaria, tuberculosis, diarrheal diseases and acute respiratory infections at the top of the list. Studies conducted by the PNG Institute of Medical Research (PNGIMR) indicate that the incidence of malaria is declining. Tuberculosis (TB) remains a problem of public health significance with drug resistant strains becoming increasingly common and extremely drug resistant (XDR) TB being reported in some areas. The HIV prevalence amongst pregnant women has stabilized at 0.56% (2013) however resistance has been observed. PNG faces health system challenges including a rapid population growth, limited resources, limited access to services, high maternal mortality ratio, double burden of communicable and non-communicable diseases, shortages of qualified human resources for health and inadequate access to essential medicines, insufficient funding for service delivery, poor laboratory capacity, and culture and beliefs of general population fuel the misuse of antibiotics. The observed state of AMR response capacity in PNG organized under the six elements of the WHO policy package on AMR is shown below. The assessment scores represent the independent view of the CSA conducted by WHO in 2016, and does not represent the situation at the time of writing the National Action Plan on AMR. Table 1. Country Situation Score Card based on the Country Situation Analysis Activity-based score* WHO policy package element: 1 2 3 4 5 6 7 1. National coordination mechanisms  2. Surveillance and laboratory capacity    3. Access to, and quality of, essential medicines    3. Rational use of medicines in humans and animals  4. Infection prevention and control   5. Research and development   * 1: Minimal activity on AMR; 7: Significant activity on AMR. Papua New Guinea National Action Plan on Antimicrobial Resistance 4 2.2 Current State of Antimicrobial Resistance (AMR) in Papua New Guinea 2.2.1 Human Health Available data to confirm the state and extent of drug resistance patterns and trends in the country are fragmented and not readily available. The Country Situation Analysis (CSA) conducted by WHO in 2016 noted this situation and recommended establishing a baseline for AMR in the country. Part of the reason at that time was the absence of a National AMR Steering Committee to coordinate all issues related to AMR in Papua New Guinea. Despite this setback, some very useful information on AMR have been gathered by the Papua New Guinea Institute of Medical Research (PNGIMR), the Central Public Health Laboratory (CPHL) and the pathology department of the Port Moresby General Hospital (PMGH), the largest referral hospital in PNG. The findings are strongly suggestive of a similar situation in the country, though a representative survey is needed to establish a clear national baseline. Table 2 presents resistance data provided by PNGIMR. Isolates were obtained from multiple studies conducted at various points in time between 2004 and 2015. A number of pathogens showed high resistance to sulphamethoxazole/trimethoprim (also known as co-trimoxazole or septrin) and tetracycline. Table 2. Resistance and susceptibility rates from PNGIMR, multiple years Antibiotic: Pathogen: N AMC AMP AZM C CIP CN CRO Shigella spp* 47 NT 91.5% R NT 55.3% R 100% S NT 100% S 23.4% I Salmonella typhi* 5 NT 80% R NT 40% R 100% S NT 100% S N. gonorrhoea** 106 100% S NT 100% S NT 1% R NT 100% S (52/52) H. influenzae*** 33 NT 61% NT 55% R NT NT 6% R 3% I S. pneumoniae*** 73 NT NT NT 10% R NT NT 100% S S. aureus # 53 NT NT NT 4% R NT 100% S NT GNB ## 27 NT 52% R NT 33% R 4% R 30% R NT Antibiotic: Pathogen: N E NA OX/MET P SH SXT TE Shigella spp* 47 NT 100% S NT NT NT 70.2% R 76.6% R 2.1% I Salmonella typhi* 5 NT 20% R NT NT NT 60% R 60% R N. gonorrhoea** 106 100% S NT NT 51% R 100% S NT 32% R H. influenzae*** 33 NT NT NT NT NT 61% R 67% R S. pneumoniae*** 73 1% R NT 27% NT NT 34% R 12% R 1% I 1% I 5% I 1% I S. aureus # 53 8% R NT 79% R NT NT 100% S 2% R GNB ## 27 NT NT NT NT NT 48% R 33% R Notes: R (Resistant), S (Sensitive), I (Intermediate) * Isolates obtained from a diarrheal disease study conducted from 2009-2011 in EHP. Majority of Shigella spp were S. flexeneri. Papua New Guinea National Action Plan on Antimicrobial Resistance 5 ** Isolates collected between 2004 and 2005 (n=52), and between 2009 and 2010 (n=54) from 3 sites: Goroka, Mt. Hagen and POM. *** Isolates obtained from meningitis cases and Aetiology of ALRI and meningitis study over last 5 years (EHP). As well as from sick visits from PCV study participants (2012-2015). # Mainly from osteomyelitis cases in 2012 from Kundiawa, but also from sick visits from PCV study participants. ## GNB=Gram negative bacteria. Largely obtained from osteomyelitis cases in 2012 from Kundiawa, but also from meningitis cases in Goroka and sick visits from PCV study participants. MDR (Resistance to 2 or more antibiotics) was common for Shigella spp (91%), Salmonella Typhi (60%), and H. Influenzae (67%). Antibiotics: AMC: Amoxicillin/Clavulanic Acid (Augmentin); AMP: Ampicillin; AZM: Azithromycin; C: Chloramphenicol; CIP: Ciprofloxacin; CN: Gentamicin; CRO: Ceftriaxone; E: Erythromycin; MET: Methicillin; NA: Nalidixic Acid; OX: Oxacillin; P: Penicillin; SH: Spectinomycin; SXT: Sulphamethoxazole/Trimethoprim (AKA: Co-trimoxazole or Septrin); TE: Tetracycline. Shigella spp. and Salmonella typhi isolates, obtained from a diarrheal disease study, also showed additional, and relatively high, resistant to ampicillin and chloramphenicol. Gram negative bacteria, largely obtained from osteomyelitis cases, showed resistance to a number of antibiotics. Most pathogens exhibited resistance to chloramphenicol. Multi-drug resistance (MDR) to 2 or more antibiotics was common for Shigella spp (91%), Salmonella typhi (60%), and H. influenzae (67%). PMGH pathology laboratory also has capacity for Antimicrobial Sensitivity Testing (AST). The laboratory performs disk diffusion susceptibility testing and focuses on supporting medical practice within the hospital. Data from 2011 showed that the PMGH lab received over 10,000 clinical samples for microbiological assessment, including urine, blood, pus swaps, and cerebrospinal fluid. From 3,246 urine samples, for example, a total of 302 (or 9%) bacterial isolates were observed. The three most common bacteria isolated were E. coli (43%), K. pneumoniae (27%), and P. aeruginosa (3%). The data, which is reported in the latest draft of the National Infection Prevention and Control Policy, also suggest varying susceptibility patterns with many organisms showing multiple drug resistant patterns. Some additional data collected during 2015 from the PMGH pathology laboratory did provide some statistics on resistant patterns. Tables 3 and 4 below summarizes resistant patterns to a number of antibiotics for those pathogens where the number of isolates was large enough to produce reliable rates. Table 3 indicates that urinary infections in adults are intrinsically resistant to penicillin, and highly resistant to ampicillin, augmentin, and co-trimoxazole. It also shows that infections from Proteus species are 100% resistant to nitrofuran. Table 3. Susceptibility rates from PMGH, urinary isolates, adults, 2015 Antibiotic: Pathogen: N Pen Amp Aug Ceftriax Cotrim Genta Cipro Nitro E. coli 358 R 14% 25% 88% 24% 89% 89% 92% Klebsiella species 187 R 2% 25% 54% 28% 61% 78% 52% Enterobacter-like species 47 R 9% 15% 60% 43% 68% 68% 38% Proteus species 37 R 24% 70% 89% 33% 73% 94% 0% All Enterobacteriaceae 629 R 11% 27% 76% 27% 78% 84% 71% Notes: R: intrinsically resistant. Pen: penicillin, amp: ampicillin, aug: augmentin, ceftriax: ceftriaxone, cotrim: co-trimoxazole, genta: gentamicin, Cipro: ciprofloxacin, nitro: nitrofuran Papua New Guinea National Action Plan on Antimicrobial Resistance 6 Table 4 indicates that wound and other conditions with pus infections are highly resistant to a number of antibiotics. Although resistant to many antibiotics, Enterobacter-like species still show important susceptibility to four main antibiotics. Table 4. Susceptibility rates from PMGH, wound and pus isolates, adults, 2015 Antibiotic: Pathogen: N Fluco Eryth Tetra c Amp Aug Ceftriax Cotrim Gent a Cipro Chlor S. aureus (MRSA and MSSA) 94 60% 76% 94% R 93% 72% Streptococcus (beta-haemolytic) 2 S n/a n/a S S n/a E. coli 62 R R R 3% 26% 71% 11% 76% 74% 26% Klebsiella species 120 R R R 2% 23% 36% 23% 44% 69% 18% Enterobacter-like species 28 R R R R 29% 82% 54% 67% 92% n/a P. aeruginosa (all ages) 46 R R R R R R R 70% 64% R Notes: R: intrinsically resistant; S: susceptible by extrapolation or intrinsically susceptible; n/a: not available. Empty cell: this antibiotic is not recommended for therapy. Flucox: flucoxacillin, erythr: erythromycin, tetra: tetracycline, amp: ampicillin, aug: augementin, ceftriax: ceftriaxone, cotrim: co-trimoxazole, genta: gentamicin, cipro: ciprofloxacin, chlor: chloramphenicol A population based survey conducted by the National Tuberculosis Program (NTP) and CPHL on the burden of drug-resistant TB in PNG in 2015 showed; among 1,182 TB patients enrolled in the study, MDR-TB was detected in 20 new (2.7%; 95% confidence intervals [CI] 1.1–4.3%) and 24 previously treated (19.1%; 95%CI: 8.5–29.8%) TB cases. No case of extensively drug-resistant TB (XDR-TB) was detected. Thirty percent (6/20) of new and 33.3 % (8/24) of previously treated cases with MDR-TB were detected in a single cluster in Western Province. 2.2.2 Animal Health Data from the animal health sector was not available at the time of writing this plan. The Department of Agriculture & Livestock (DAL) and the National Agriculture & Quarantine Inspection Authority (NAQIA) have been trying to establish baseline information for AMR in animals in PNG but have not been able to do so. This is an important activity covered under this plan, and following implementation, data will be generated through baseline studies proposed by the DAL and NAQIA to establish the AMR situation for animals in PNG. Papua New Guinea National Action Plan on Antimicrobial Resistance 7 3. Multi-Sectoral Governance on AMR In Papua New Guinea, a multi-stakeholder Governance Committee was proposed by the Country Situation Analysis (CSA) that was conducted by the WHO in 2016. The proposal was discussed and accepted by stakeholders that attended two workshops organized by the NDoH and the WHO in September 2016 and January 2017. Participants from the NDoH, Department of Agriculture (DAL), NAQIA, Papua New Guinea Institute of Medical Research (PNGIMR), University of Papua New Guinea (UPNG) and multilateral stakeholders including the WHO, Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE), Burnet Institute, Medicines Sans Frontier (MSF) and the private sector attended. The Multi-Sectoral Governance Framework for AMR as accepted for PNG is in line with the One Health approach required to provide strong and significant leadership to recognize the importance of AMR in Papua New Guinea. Three main bodies will provide a strong leadership program to profile AMR as a national priority: 1. National AMR Steering Committee with a decision making role 2. AMR Secretariat with a dual coordination and secretariat role 3. AMR Technical Working Groups to implement the plan and report to the steering committee.  Nominated focal points to support the secretariat  Advisory roles: Medical Society AMR Committee, Pharmacy Board of PNG, National CODEX Committee, and other external consultants as needed Figure 1: Governance Framework for AMR in Papua New Guinea 3.1 National AMR Steering Committee The National AMR Steering Committee (NAMRSC) is the highest level of governance with some degree of authority for AMR in PNG. Reporting to the Minister for Health, it will have an annual rotating chair amongst the Secretary for Health, Secretary for Agriculture and Livestock and Managing Director for Conservation & Environment Protection Authority (CEPA). The members shall be representatives from the organizations as outlined below. Papua New Guinea National Action Plan on Antimicrobial Resistance 8 Members: Three (3) Co-chairs: Secretary for Health, Secretary for Agriculture & Livestock and Managing Director for Conservation and Environment Protection Authority (CEPA)  National Department of Health o CPHL o Pharmaceutical Service Standard Branch (PSSB) o Infection Prevention & Control (IPC) Committee o (legal rep as advisory role or ad hoc member when needed not regular member)  Department of Agriculture and Livestock  Conservation and Environment Protection Authority  National Agriculture Quarantine and Inspection Authority  Institute of Medical Research  University of Papua New Guinea  Medical Society of PNG  Nurse Association of PNG  Pharmaceutical Society of Papua New Guinea  Veterinary Clinic representation  Non-government Organizations (NGO) representation  Representative of the private sector (pharmacy and hospital) Observers:  WHO and Food & Agriculture Organization(FAO) of the United Nations  Department of Foreign Affairs & Trade (DFAT)  Centre for Disease Control (CDC) /United State Agency International Development (USAID)  Japanese International Cooperate Agency (JICA)  Global Fund (Principle recipients)  Burnet Institute  Other relevant donors/partners Advisory bodies:  Medical Society AMR Committee  External Consultants (as needed)  Pharmacy Board of PNG  National CODEX Committee Term of Reference:  Coordinate all efforts to address AMR in the country  Oversee the implementation of the national action plan  Membership should reflect all sectors involved in containing AMR at senior level  Chair to rotate every year among the three co-chairs  Meet twice a year (and other times on an ad-hoc basis)  Have some degree of authority  Report to the Minister of Health  Supported by the AMR secretariat and Technical Working Groups 3.2 AMR secretariat The National Department of Health (NDoH) through its Pharmaceutical Service Standard Branch (PSSB) is providing the AMR Secretariat for AMR response in Papua New Guinea. Papua New Guinea National Action Plan on Antimicrobial Resistance 9 The Secretariat is tasked with coordination between different stakeholders and ensuring the AMR governance structure is operational. To better perform its role the AMR Secretariat needs to be appropriately resourced. Supported by focal points from:  Central Public Health Laboratory (CPHL)  Managers of Disease Programmes  DAL Chief Codex Officer  Chief Veterinarian  Chief Pediatrician  Chief Physician  Chief Surgeon  Chief Obstetrician  Representative from the private sector  Infection Control Committee  WHO and FAO Terms of Reference:  Have dedicated personnel  Service two roles: o The focal point for national AMR data, information collection and sharing, and resources in the country o Secretariat for the AMR Steering Committee and Technical Working Group.  Support Monitoring &Evaluation (M&E) of the implementation of the AMR national action plan including the operational plan  Provide brief update in the National Antimicrobial Resistance Steering Committee (NAMRSC) meetings and the Technical Working Groups (TWG) quarterly meetings  Produce, at least, a yearly report with an inventory of AMR information, including AMR patterns and M&E of the national plan  Supported by nominated TWG focal points 3.3 Technical Working Groups The AMR Technical Working Groups shall be internally organized within the National Department of Health (NDoH), the Department of Agriculture (DAL) and the Conservation and Environment Protection Authority (CEPA). The Technical Working groups will be responsible for overseeing implementation of national AMR response within each sector and report to the National AMR Steering Committee. Three technical working groups:  National Department of Health (Chair – Deputy Secretary)  Department of Agriculture and Livestock (Chair – Deputy Secretary)  Department of Environment & Conservation(Chair – Deputy Secretary) Terms of Reference:  Members should be composed from a sub-group of technical experts from the AMR Steering Committee Members  Should meet on a regular basis (and ad hoc when needed)  Leads for the implementation of the national action plan activities  Provide regular reporting on the National Action Plan including the operational plan implementation to the AMR steering committee  Supported by the AMR secretariat Papua New Guinea National Action Plan on Antimicrobial Resistance 10 4. Papua New Guinea National Action Plan on Antimicrobial Resistance (AMR) – One Health Approach The PNG National Action Plan on AMR is a multi-stakeholder plan for the sectors directly impacted by AMR; including human health, animal health, and the environment. The plan serves as the country road map for action on AMR and therefore, requires the political commitment at the highest level to support the strategies and interventions detailed in the operational plan. The NDoH, DAL and the CEPA will take leading roles based on the governance framework and ensure the One Health approach is observed and maintained by all stakeholders. Vision: A country that continues to benefit from the use of effective antimicrobials for the treatment of infections in humans and animals for a long time. Mission: For Papua New Guinea to do its part to minimize the spread of drug resistance so that our country can continue to benefit from effective antimicrobials. 4.1 Strategic Objectives Objective 1: Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance Strategies: 1. Finalize the national action plan on AMR 2. Establish a multi-sectoral mechanism for finalizing and implementing the National Action Plan 3. Ensure sustainable investment in combating AMR Objective 2. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training Strategies: 1. Promote regular information sharing on the situation of AMR and use of antimicrobials across sectors 2. Raise awareness of health-care professionals Objective 3. Strengthen surveillance, diagnostic capacity and research on AMR Strategies: 1. Develop a national AMR surveillance system with a reference laboratory 2. Strengthen food safety capacity to combat AMR 3. Strengthen research and information sharing on AMR Papua New Guinea National Action Plan on Antimicrobial Resistance 11 Objective 4. Strengthen sanitation, hygiene and infection prevention and control across all sectors Strategies: 1. Establish a national infection prevention and control programme to strengthen hospital infection control 2. Strengthen infection control for MDR/XDR-TB patients in health-care facilities, community, public spaces and transport 3. Promote good infection control and biosecurity practices in animal husbandry Objective 5. Strengthen appropriate access and optimize the use of antimicrobial medicines in all sectors Strategies; 1. Strengthen regulations to promote responsible use of antimicrobials with prescription only 2. Strengthen procurement and supply of antimicrobials Papua New Guinea National Action Plan on Antimicrobial Resistance 12 5. Implementation, Monitoring and Evaluation The National Action Plan on Antimicrobial Resistance 2019 – 2023 serves as the national road map for action on AMR in Papua New Guinea. The lead government departments responsible for implementing this plan are the National Department of Health (NDoH), Department of Agriculture and Livestock (DAL) and the Conservation and Environment Protection Authority (CEPA) as direct impact sectors of AMR. Various other stakeholders including national, international and multilateral organizations that support the work of these three departments on AMR will implement certain activities within their specialty areas for example; the PNG Institute of Medical Research shall be involved in conducting baseline studies and operational researches on AMR.. Activities for implementation are aligned to the Strategic Objectives of the Plan and are detailed in the Operational Plan, which is a 4-year plan until 2023. Certain activities have marked funding while others are intended for potential counterpart funding by government agencies and/or international and multilateral organizations such as the DFAT, WHO or FAO. During the period of implementation, each implementing agency will report on the progress of their activities and achievement of activity related indicators, be it process or impact indicators. The monitoring reports will be presented to the respective TWG meetings chaired by the Deputy Secretary for each Department. These progress reports will be compiled by the AMR Secretariat for presentation to the National AMR Steering Committee annually for review and decisions on next steps. At this stage impact indicators for monitoring and evaluation of the country responses to AMR has not been established. These indicators will form part of the discussions during the bi-annual monitoring and evaluation meetings for the National Action Plan. All stakeholders will be engaged during those discussions to formulate appropriate impact indicators based on data available from baseline surveys. Progress will be reported to the Minister for Health and to WHO to measure the country response to AMR and how PNG is performing compared with other countries. Any new findings and feedbacks observed during implementation will serve as the basis for review of the country strategies and actions to combat AMR and ensuing review of the PNG National Action Plan on AMR 2019– 2023. P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 3 6. Operational Plan (4 Years: 2019-2023) SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR 1. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance 1.1 Finalize the national action plan on AMR 1.1.1 Establish roles and responsibilities for key stakeholders and ensure commitment Finalize the national action plan with a four year operational plan on AMR 2019 2021 10,000.00 AMR secretariat NDoH/WHO High level signing completed Mapping out of responsibilities of authority of the food chain from farm to fork 2019 2021 12,200.00 NDOH DAL WHO FAO DAL/NAQIA Mapping report finalized and disseminated 1.1.2 Develop a budget for implementation of the action plan and identify funding sources Facilitate with key stakeholders for costing activities identified in their respective activities 2019 - AMR Secretariat - Costing completed 1.1.3 Regular monitoring and evaluation of the implementation of the national action plan Hold quarterly meetings of the TWG chairs to discuss implementation of the national action plan 2019 2021 18,300.00 TWG and AMR secretariat Quarterly meeting minutes disseminated Bi-annual meeting for M&E of AMR action plan implementation and review group to draft amendments to the national action plan for discussion with stakeholders. 2020 2023 100,500.00 AMR steering committee Bi-annual review conducted Review/endorsement of amended AMR National Action Plan once a year at AMR Steering Committee meeting 2019 2023 70,750.00 AMR steering committee AMR secretariat Review conducted 1.1.3 Inclusion of the national action plan into the Medicines and Cosmetics Act review Inclusion of AMR as a topic in national stakeholders’ consultation on Medicines and Cosmetics Act 1999 2019 10, 000.00 PSSB/WHO WHO DFAT Appropriate clauses included in revised Act Conduct a consultation to ensure incorporation of veterinary medicines into the Medicines and Cosmetics Act 1999 2020 6,100.00 NDOH DAL Appropriate clauses included in revised P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 4 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR NAQIA Act Delegate power of authority for veterinary regulation and capacity building to detect unregistered antimicrobials under the national medicines policy to National Agriculture Quarantine Inspection Authority (NAQIA) 2019 2120 NAQIA NAQIA empowered to inspect Hold biannual meetings of the Pharmaceutical Society including chief veterinarian (OIE representative) / Chief Codex Officer 2019 2021 13,725.00 NDOH NAQIA / DAL Quarterly meeting minutes shared 1.1.4 Demonstrate the economic impact of AMR on PNG Conduct economic and biosecurity impact study of AMR on PNG to inform ongoing priorities 2019 2023 120, 500.00 NDOH DAL NAQIA IMR Burnet Institute Findings published Conduct operational research training courses to strengthen capacity for surveillance research 2019 2021 14, 030.00 Burnet Institute Training course conducted 1.2 Establish a multi-sectoral coordinating mechanism to oversee the implementation of the plan 1.2.1 Establish an AMR steering committee supported by an AMR secretariat High level agreement for establishment of the AMR steering committee and secretariat 2019 8, 000.00 NDOH DAL DEC NDOH AMR steering committee first meeting held Develop working arrangements for implementation of the national action plan (Operational support) 2019 2023 30,500.00 All stakeholders AMR Secretariat Operational plan endorsed 1.2.2 Set up technical working groups to support implementation of the national action plan Set up technical working group in NDOH and identify chair 2020 5, 000.00 NDOH First meeting held Set up technical working group in DAL and identify chair 2020 5, 000.00 DAL First meeting held Set up technical working group in DEC and identify chair 2020 5, 000.00 DEC First meeting held Hold regular TWG meetings 2019 2023 30,500.00 TWG AMR Secretariat Regularly meeting minutes shared to stakeholders Hold an annual stakeholder meeting on AMR 2017 2023 200,000.00 All stakeholders Annual meeting minutes shared to stakeholders 1.3 Strengthen national regulations and quality assurance to ensure safeguarding of effective antimicrobials 1.3.1 Legislate for prescription only sales of antimicrobials in licensed pharmacies P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 5 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR Introduce legislation (or regulation) to mandate large producers to have a veterinarian/para veterinarian to monitor the use of antimicrobials 2019 2021 30, 000.00 DAL NAQIA Legislation introduced 1.3.2 Improve legislation of AMR in the animal sector Legislate against feeding offal to animals to stop transmission of AMR in livestock 2020 - DAL NAQIA Legislation introduced Improve regulation of offal consumption by humans to avoid transmission of infections 2021 - DAL NAQIA Updated regulation endorsed Improve legislation for animal mid-product handlers to be free from TB and skin diseases 2021 - DAL NAQIA Updated regulation endorsed Review legislation of the Animal Slaughter Act to ensure animals are free of TB and other pathogenic microorganisms 2019 2021 30,500.00 DAL NAQIA Review report finalized Develop meat inspection standards that will cover quality assurance from farm to fork. 2019 2021 10,764.54 NAQIA NDOH DAL Inspection standards developed and printed 1.3 Ensure sustainable investment in combating AMR 1.3.1 Create an enabling environment for access to effective antimicrobials (e.g. infrastructure, roads, supply chain) Collaborate with other partners to strengthen vaccination roll out capacity including cold chain 2019 2020 2,250,000 ILTA – HHISP DFAT M-Supply rolled out to all AMS, TS and PHs Strengthen mSupply inventory database for monitoring antimicrobial consumption in the public sector 2019 2020 400,000 ILTA - HHISP DFAT mSupply rolled out to all AMS, TS and PHs Develop a roadmap to establish a Medicines Information Centre with emphasis on rational use of antimicrobials (including food and veterinary medicines) 2019 2023 30,500.00 NDOH/PSSB WHO Roadmap developed Improve collaboration of CPHL, PMGH and UPNG Pathology services for AMR testing 2019 20223 30,500.00 CPHL PMGH UPNG Joint report shared to stakeholders Improve dissemination of AMR data from laboratory services to decision makers and researchers for evidence-based action 2019 2023 18,300.00 CPHL IMR AMR Secretariat 1.3.2 Invest in appropriate human resources to ensure sustainable implementation of the national action plan Ensure one dedicated staff for AMR secretariat 2017 - 36,600.00 AMR secretariat HR recruited P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 6 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR 2020 1.4 Relevant legislation in place to combat AMR 1.4.1 Review of relevant legislations relevant to AMR Map out the legislations that are relevant to combating AMR in PNG (review health practitioners bill, food and sanitation Act and regulation, and other legislations for applicable legislations) 2018 2019 10, 000.00 All stakeholders Mapping report finalized Hold a stakeholder workshop to review existing legislation and identifying revisions required 2017 15,250.00 All stakeholders Revisions agreed upon Update relevant legislations 2018 2020 45,750.00 All stakeholders Legislation updated and adopted 2. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training 2.1 Promote regular information sharing on the situation of AMR and use of antimicrobials across sectors 2.1.1 Develop awareness raising materials and conduct awareness activities Develop IEC materials on AMR for the general public and policy makers 2019 28,975.00 WHO Burnet Institute IEC materials printed Conduct regular AMR advocacy and awareness using all means of communication/ mass media 2019 2023 61,000.00 AMR secretariat and TWGs 10 awareness raising communication conducted annually Hold annual awareness campaign to celebrate World Antibiotic Awareness Week (WAAW) 2019 2023 30,500.00 All stakeholders WHO/FAO Awareness week campaigns conducted annually Conduct regular awareness raising for farmers, importers, exporters, food processors, animal production officers 2019 2023 29,073.21 DAL NAQIA 10 awareness raising communication conducted annually Engage & train community leaders, NGO’s , Civil societies, churches, sports groups to raise awareness on AMR 2019 2021 30,500.00 Burnet Institute Training conducted Conduct regular AMR advocacy through free air time of talk back shows 2019 2023 40,000.00 Media, All stakeholders 8 talk back shows held with AMR messaging annually Conduct an awareness raising workshop for private pharmacies on AMR and rational use of antimicrobials 2019 2021 38,300.00 Private pharmacies NDoH Workshop held P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 7 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR DAL 2.1.2 Promote effective sanitation and hand hygiene in the community setting Conduct annual hand hygiene day activities 2019 2023 45,750.00 NDOH Activities held Develop promotional materials to raise awareness of hand hygiene and effective sanitation in the community 2020 29,073.21 NDOH IEC materials printed and disseminated Awareness Campaign, talk back show on Radio, TV on cough checks & healthy living environment practices 2019 2023 61,000.00 IMR NDOH WHO media 8 sessions held with AMR messaging annually 2.1.3 Develop simple, translated advocacy materials on the responsible use of antimicrobials for use (IEC materials) Conduct perception survey on general public understanding of AMR and responsible use to inform targeted messaging 2020 40,000.00 IMR Perception survey report finalized Design, Develop and print simple advocacy messages targeting general public 2020 28,975.00 NDOH Burnet Institute IEC materials printed and disseminated Based on the survey results; to apply its results into radio messages for general public 2019 2023 28,975.00 NDOH Burnet Institute Radio messages conducted Design and print posters, brochures and booklets to raise awareness on introducing two vaccines in the communities. 2020 23,665.00 WHO IEC materials printed and awareness carried out in communities 2.1.4 Develop an educational programme for schools (all levels) on AMR and rational use with key targeted messages Revise the Department of Education curriculum on Healthy Living to capture AMR and basic sanitation and hand hygiene awareness raising in all schools 2019 2021 48,096.06 NDoH Department of Education Burnet Institute Curriculum revised and integrated Incorporate hand hygiene practices into kindergarten and pre-school curriculum 2019 2020 40,000.00 NDoH Burnet Institute Department of Education Hand hygiene activities undertaken Incorporate hand hygiene and basic sanitation into school curriculums 2019- 48,096.06 NDoH Hand hygiene P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 8 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR 2021 Burnet Institute Department of Education activities undertaken 2.2 Raise awareness of health-care professionals 2.2.1 Empower community health workers and other cadre of health workers to promote awareness in rural areas with appropriate messaging and language Conduct workshop on AMR for key target groups including CHW, Aid post orderly, Village Health Volunteers 2019 2021 620,000.00 NDOH 20 workshops conducted 2.2.2 Develop targeted messaging to health-care professionals and health care students and strengthen university curricular for health professionals on AMR Mapping of existing content on AMR in university curricula 2020 35,000.00 UPNG, Mapping report finalized Insert in the training curriculum the relevant subject on AMR and rational use for all health professional training institutions. 2020 2021 20,000.00 UPNG Curriculum updated and integrated Conduct perception surveys on healthcare workers understanding of AMR and rational use to inform targeted messaging 2019 2021 40,000.00 IMR Perception survey report disseminated Develop targeted IEC materials for health-care professionals and students 2019 2021 28,975.00 Burnet Institute WHO IEC materials developed and disseminated Conduct 4 regional MTC training for health-care workers on the rational use of antimicrobials and AMR 2019 2021 30,500.00 NDOH Burnet Institute/AAHL 4 trainings conducted Develop targeted messaging and IEC materials for agriculture and veterinary professionals and students 2019 2020 22,875.00 NAQIA Burnet Institute IEC materials developed and disseminated Update existing curriculum for agriculture and veterinary students to include AMR and rational use of antimicrobials 2020 48,096.06 UPNG Burnett Institute Curriculum updated and integrated P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 1 9 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR 3. Strengthen surveillance, diagnostic capacity and research on AMR 3.1 Develop a national AMR surveillance system with a reference laboratory 3.1.1 Strengthen CPHL national support capacity for training on microbiology and quality antimicrobial susceptibility testing Identify current capacity in-country as well as specialists to identify strengths and weaknesses for antibiotic susceptibility testing 2019 2020 30,000.00 CPHL PNGIMR External consultation report Strengthen CPHL capacity based on the weaknesses identified 2019 2021 100,000.00 CPHL Engage an international long-term adviser (ILTA) to strengthen CPHL activities for programmatic management of drug resistance TB and support the development of an integrated disease surveillance and response system 2017 154,029.00 ILTA - HHISP DFAT ILTA engaged Strengthen the role of CPHL as a resource for laboratory testing within the national diseases integrated surveillance system 2020 50,000.00 CPHL Surveillance and Emergency Response Unit (NDoH) System developed 3.1.2 Strengthen laboratory capacity for AMR surveillance Conduct regular sensitivity/resistance tests on standard antimicrobials from across the country through CPHL and PNGIMR 2019 2021 93,903.40 CPHL PNGIMR Antibiogram developed and launched Build capacity to provide bacterial external quality assurance (EQA) for bacterial antibiotic susceptibility testing 2020 46,951.70 CPHL Capacity built Implement EQA programmes in all laboratories that conduct antibiotic susceptibility testing 2019 2020 46,951.70 CPHL EQA conducted bi annually at laboratories Build laboratory capacity of four pilot regional hospital for antibiotic susceptibility testing for sentinel site surveillance 2019 2021 120,000.00 CPHL PNGIMR Capacity built 4 regional hospitals Develop drug susceptibility testing capacity for other bacterial diseases of public health importance at CPHL. 2019 2020 46,951.70 PHA CPHL DST for anti bacterials conducted. Develop regional /provincial hospital laboratories testing facilities to support CPHL whilst retaining CPHL as the reference laboratory. 2019 2020 366,000.00 CPHL Burnet Institute Regional hospitals capacities upgraded Develop regional second veterinary laboratory in Lae for AMR surveillance (agriculture hub) 2019 2021 366,000.00 DAL Second veterinary laboratory developed P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 0 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR Increase sample through-put for cultures, AST, anti-parasitic testing and antibiotic residue testing including procurement of sample transport containers and transport costs. 2019 2023 69,753.50 NAQIA Residue testing conducted Conduct training for meat inspectors and laboratory personnel on relevant sampling techniques for the different sample types I.e. diagnostic samples, cultures, environmental samples and animal feed samples. 2020 45,000.00 NAQIA Trainings conducted Improve existing laboratory capacity building for antimicrobial testing for NAQIA National Animal Health and Food Testing Laboratory. 2019 2021 25,925.00 NAQIA Antimicrobial testing conducted Build capacity for data collection, analysis and dissemination through purchasing of necessary ICT equipment for data recording communication and resource information gathering 2020 15,250.00 NAQIA AMR data collected, analysed and disseminated Develop database for real-time collection of information on emergence of AMR 2019 2020 30,000.00 PNGIMR Burnet Institute Database developed Strengthen NAQIA National Animal Health and Food Testing Laboratory capacity for training on microbiology and quality antimicrobial susceptibility testing including consumables and regents for testing. 2019 2021 29,788.60 NAQIA Capacity strengthened 3.2 Strengthen food safety capacity to combat AMR 3.2.1 Build capacity for antibiotic residue testing (food safety) Develop NARI Laboratory, CODEX testing capacity for antibiotic residues 2019 2021 59,577.20 DAL NARI Antibiotic residue tests results reported 3.2.2 Promote random and regular testing on meat and other food product imports for AMR pathogens and antibiotic residues Undertake random sample collection and testing for AMR and antibiotic residues. 2019 2021 69,753.50 NAQIA Number of sampled tested and reported 3.3 Strengthen research and information sharing on AMR 3.3.1 Promote collaborative research projects between universities, departments and research institutes on AMR in human and animal health and the environment Provide research grant for human and animal health research for addressing knowledge gaps in combating AMR 2020 2021 152,500.00 All stakeholders 5 publications submitted to journals 3.3.2 Conduct bacteria susceptibility survey/profile (pathogen/regions) Establish a programme activity for sample collection, testing and data consolidation. 2019 2021 10,980 NAQIA A Sampling Framework developed P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 1 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR Conduct sentinel site surveillance to profile AMR in the human health and animal sector including aquaculture 2019 2021 152,500.00 NAQIA NARI IMR CPHL PMGH pathology lab Burnet/AAHL NFA Surveillance report published 3.3.3 Ensure sharing of AMR surveillance and use data Regular sharing of AMR surveillance and antimicrobial consumption to the stakeholders and other regional and international stakeholder / authorities 2019 2021 5,776.40 AMR secretariat Reports disseminated 4. Strengthen sanitation, hygiene and infection prevention and control across all sectors 4.1 Establish a national infection prevention and control programme to strengthen hospital infection control 4.1.1 Finalize the national infection control policy Develop and finalize and endorse the national infection control policy 2019 25,925.00 NDOH NDOH National IC policy endorsed Print and disseminate the national infection control policy 2020 6,100.00 NDOH 500 copies printed Establish/strengthen a national infection control committee 2019 2021 13,725.00 NDOH IC committees established in all tertiary hospitals Revise National IPC Guidelines based on above policy 2020 7,625.00 NDOH WHO IPC guidelines revised and launched Review public health Act for infection control including handling food (SPS police sanitation and phyto-sanitation) 2019 2021 13,725.00 NDOH Act review conducted 4.2 Strengthen infection control for MDR/XDR-TB patients in health-care facilities, community, public spaces and transport 4.2.1 Strengthen health-care workers occupation health and safety Improve TB program coordination and implementation 2018 430,000 ILTA - HHISP DFAT ILTA engaged Improved TB program coordination and implementation Ensure continuing supply of PPEs in particular N95 respirator in health care facilities 2019 2021 166,000.00 PHO DGH No stock out of N95 reported P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 2 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR Ensure appropriate equipment for FIT test equipment and conduct regular trainings in health-care facilities 2020 2021 105,000.00 NDoH DGH Burnet Institute 2 trainings conducted annually Investigate appropriate administrative and engineering interventions for the prevention of TB transmission in health-care facilities in Daru, Lae and East Sepik 2019 2020 52,500.00 NTP PHO DGH Reports disseminated Conduct regular TB screening for hospital health-care workers twice a year 2019 2020 249,000.00 PHO DGH No of screenings conducted Upgrade laboratory testing for TB testing in animals 2019 2021 100,000.00 DAL NAQIA FAO Laboratory upgraded Mandate the testing of TB in animals and monitor TB in animals 2019 2023 31,930.00 DAL NAQIA FAO TB testing in animals made mandatory 4.2.2 Disposal of expired drugs and non-registered drugs and medical waste Technical assistance to assess medical disposal system including disposal of antimicrobials and recommend action to be taken 2019 35,000.00 NDoH WHO Report disseminated Develop guidelines on disposal of unused antibiotics (including veterinary medicines 2019 2020 63,830.00 DAL NDoH NAQIA CEPA Guidelines published Establish a model site for the disposal a)pharmaceuticals, b) medical waste and, c) veterinary waste 2019 2020 610,000.00 NDOH DAL CEPA 3 model sites established and checklist developed 4.3 Promote good infection control and biosecurity practices in animal husbandry 4.3.1 Strengthen infection prevention and control in animal husbandry Continue to conduct infection prevention and control in farms, slaughter houses and Feed Mills 2019 2023 40,000.00 NAQIA Infection Control visits undertaken Microorganism profiling in slaughter houses to be conducted for surveillance of AMR and antibiotic residues 2019 – 2023 6011.50 NAQIA Microorganism profiling conducted Strengthen capacity for inspection of safe food 2017 2020 8,753.50 NAQIA Number of staff trained 5. Strengthen appropriate access and optimize the use of antimicrobial medicines in all sectors P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 3 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR 5.1 Strengthen regulations to promote responsible use of antimicrobials with prescription only 5.1.1 Promote prescription only use of antimicrobials (legislation and enforcement) in the human and animal sector Promote prescription only use and veterinary supervision of the use of antimicrobials in the animal husbandry sector, aquaculture sector 2019 2023 20,000.00 DAL NAQIA/ NFA Reports submitted Conduct Spot checks of supply chain to monitor over the counter sales of antimicrobials 2019 2022 40,000.00 PSSB police customs NAQIA Annual report developed and published Inspection of spot inspections at markets to capture illegal sales of antimicrobials 2019 2023 40,00.00 PSSB police customs NAQIA Annual report developed and published Conduct training for capacity building of veterinary inspectors 2019 2023 45,750.00 NAQIA Training conducted 5.1.2 Develop PNG antimicrobials guidelines based on available AMR for human and animal use and development of new antimicrobials and to mainstreamed into the standard treatment guidelines Conduct baseline survey on the consumption of antimicrobials in the animal and aquaculture sector 2019 2020 120,000.00 DAL NAQIA FAO / NFA Report published Conduct baseline survey on the consumption of antimicrobials in the health sector 2019 2020 120,000.00 NDOH WHO Report published Strengthen the national health information systems to incorporate antimicrobial consumption and resistant patient data 2019 2020 45,000.00 NDOH Data on AMR captured To develop national antimicrobial guidelines for human use based on resistance and consumption data 2020 20,000.00 NDOH Guidelines published Develop list of veterinary antimicrobials for pet and food animals 2019 10,000.00 DAL NAQIA List published 5.1.3 Regular update and dissemination of the standard treatment guidelines based on available antibiograms for evidence based empirical treatment Meetings for disease groups to integrate antimicrobial guidelines into STGs for human use 2020 30,500.00 NDOH Meeting conducted Update STGs for human use based on the disease groups consensus 2020 20,000.00 PSSB STGs updated Meetings for veterinary practitioners to develop STGs for animal use and 2020 30,500.00 NAQIA Meeting conducted P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 4 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR integrate antimicrobial guidelines Update STGs for use based on the veterinary practitioners consensus 2020 20,000.00 NAQIA Veterinary STGs published Conduct workshop to review and update STGs including an informational page on AMR developed 2020 30,500.00 PSSB AMR informational page finalized Incorporate AMR informational page into all STGs in human and animal health sectors 2018 10,000.00 NDOH DAL NAQIA AMR informational page inserted into all STGs Develop the STGs for surgery 2022 10,000.00 NDOH STG for surgery printed Printing and dissemination of 10,000 units of STGs 2019 2020 15,250.00 NDoH 10,000 units distributed 5.1.4 Review the drug catalogue (A,B,C etc.) in particular for antibiotics Meeting of technical group to review antimicrobials in the Medical and Dental Catalogue 2012 2019 30,500.00 NDOH/PSSB Review completed 5.1.5 Establish Medicines Therapeutic Committee in all hospitals (public and private) Conduct training workshops for MTCs in collaboration with disease control programmes (HIV, Malaria, TB) 2019 15,250.00 NDOH/PSSB Training completed Conduct quarterly monitoring of functionality of 4 regional hospital MTCs 2019 2020 15,250.00 NDOH/PSSB Quarterly monitoring reports shared with 4 hospitals Conduct internal prescription audits in 4 regional hospitals 2019 2020 30,000.00 NDOH/PSSB Audits conducted Annual review of internal prescription audits 2019 2020 15,000.00 NDOH/PSSB Report developed Roll out of internal prescription audits to all hospitals 2019 2020 45,000.00 NDOH/PSSB Audits conducted in 20 hospitals 5.1.6 Increase capacity building for responsible prescribing in the human and animal sectors Strengthen capacity of para-veterinarians to enable restricted prescribing under supervision by a superior 2019 2020 75,000.00 NAQIA UPNG FAO No of para veterinarians trained P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 5 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR Strengthen capacity of rural health-care workers and pharmacists to prescribe/dispense antimicrobials responsibly 2019 2021 105,000.00 NDOH UPNG PHAs WHO No of health workers trained 5.1.7 Strengthen border control for detection of unregistered antimicrobials being brought into PNG Strengthen capacity for border controls including declaration of all antimicrobials and food products being brought into the country 2020 37, 743.75 PNG Customs NAQIA No of trainings conducted for border officers 5.1.8 Strengthen patient information and counseling Establishment and strengthening of medicine information system 2019 2020 15,000.00 NDOH/PSSB Medicines information Service established Improve labelling of prescriptions including a cautionary label to complete the prescription 2020 1000.00 NDOH New prescription form with labelling rolled out 5.1.9 Strengthen the appropriate use of traditional medicine and its use of antimicrobials Strengthen the legislation to include the commercialization of traditional medicines 2019 2021 35,000.00 NDOH Revised legislation endorsed Establish a registry of traditional medicine practitioners 2020 20,000.00 NDOH Registry established Promote the appropriate use of traditional medicine 2019 2021 20,000.00 NDoH UPNG Trainings conducted 5.2 Strengthen procurement and supply of antimicrobials 5.2.1 Strengthen product registration of antimicrobials to ensure quality assured antimicrobials Introduce a module of antimicrobial procurement and supply into planned trainings on PSM 2019 2020 50,500.00 NDOH/MSDP Module incorporated Strengthen capacity of medicine evaluators and GMP inspectors on prequalification of antimicrobials including regular training workshops 2019 2020 91,500.00 NDOH WHO No of staff trained on assessment of dossiers Introduce AMR issues into the bi-annual pharmaceutical inspectors conference specific to antimicrobials and falsified medicines for all relevant enforcement agencies 2019 2023 60,500.00 NDOH AMR session held at conference Conduct training of veterinary medicine assessor 2020 18,300.00 DAL NAQIA Trainings conducted P a p u a N e w G u in e a N a tio n a l A c tio n P la n o n A n tim ic ro b ia l R e sista n c e 2 6 SUB-ACTIVITY DATE COST (USD) IMPLEMENTER SOURCE OF FUNDING INDICATOR 5.2.2 Ensure access to quality antimicrobials in PNG Implementing good distribution and good storage practices along the supply chain through development of national GSP and GDP guidelines 2019 2023 45,750.00 NDOH Number of GSP and GDP inspections conducted Upgrade 2 district hospital pharmacies in the Central Province taking into consideration proper conditions for storage as a pilot for ideal storage conditions for antimicrobials. 2019 61,000.00 PHAs NDOH/PSSB 2 pharmacies upgraded and checklist developed 5.2.3 Develop a road map for a phase establishment of the Medicines Quality Control Laboratory (NMQCL) Establishment of the MQCL to facilitate the monitoring of the quality of medical products including antimicrobials 2019 2020 800,000.00 WHO NDOH NMQCL established to facilitate monitoring of the quality of medical products Strengthening NMQCL capacity for antimicrobial quality testing including reference library and technologies 2018 2021 91,500.00 NDOH ISO accreditation Conduct a forum with suppliers on the importance of quality antimicrobials 2020 15,000.00 WHO PSSB Forum conducted Strengthen capacity for inspection of safe food 2019 2023 67,938.75 NAQIA Training workshop held Cost Summary of Operational Plan (USD) Total Cost (USD): 11, 211,020.00 Funded (USD): 3,262,029.00 Unfunded (USD): 7,948,991.09 TOTAL COST: 11,436,643.34 Papua New Guinea National Action Plan on Antimicrobial Resistance 27 Glossary Antimicrobial resistance (AMR) – Refers to the natural phenomenon where antimicrobials can no longer be used effectively against infectious diseases caused by microorganisms (bacteria, fungi, viruses and parasites). Antimicrobials – Are medicines that have antimicrobial activity against pathogenic organisms (such as antibiotics, antifungals, antivirals, antimalarial, and anthelmintic) and are used for humans, animals and agriculture, for the purpose of treating or preventing infectious diseases, or for use as growth promoters in animal feeds. Extensive Drug Resistance (XDR) - Extensively drug-resistant TB (XDR TB) is a rare type of multidrug-resistant tuberculosis (MDR TB) that is resistant to isoniazid and rifampicin, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin) Multi Drug Resistance (MDR) – Is the resistance developed by bacteria to two or more antibiotics from different classes One Health – Is an approach that recognizes that the health of people is connected to the health of animal and the environment and therefore the different stakeholders including health, agriculture and environment have to work together to address AMR. Papua New Guinea National Action Plan on Antimicrobial Resistance 28 Contributors Australia Department of Foreign Affairs and Trade (DFAT) Burnet Institute Central Public Health Laboratory (CPHL) City Pharmacies Conservation and Environment Protection Authority (CEPA) Department of Agriculture and Livestock (DAL) Food and Agriculture Organization (FAO) Johnston’s Pharmacies Medicines sans Frontier (MSF) National Agriculture and Quarantine Inspection Authority (NAQIA) National Agriculture and Research Institute (NARI) National Fisheries Authority (NFA) National Department of Health (NDoH) Papua New Guinea Institute of Medical Research (PNGIMR) Port Moresby General Hospital (PMGH) University of Papua New Guinea, School of Medicine & Health Sciences World Health Organization, PNG Country Office (WHO) World Organization for Animal Health (OIE), PNG delegate World Vision International, PNG Office Papua New Guinea National Action Plan on Antimicrobial Resistance 29 References 1. PNG Ministry of Health and World Health Organization, Papua New Guinea Pharmaceutical Country Profile. National Capital District, 2012. 2. World Health Organization, Country Cooperation Strategy at a glance, May 2014. 3. Papua New Guinea National Medicines Policy, 2014. 4. World Health Organization and National Department of Health, Papua New Guinea Country Situation Analysis – Antimicrobial Resistance, October 2016 5. World Health Organization, Global Action Plan on Antimicrobial Resistance, 2015 6. Aia P, Kal M, Lavu E, John LN, Johnson K, Coulter C, et al. (2016) The Burden of Drug Resistant Tuberculosis in Papua New Guinea: Results of a Large Population-Based Survey. PLoS ONE 11(3)