Qatar National Antimicrobial Resistance Action Plan (NAP) 2024-2030

1. Governance Structure ........................................................................................................................................................................ 14

2. Awareness, Education and Behavior Change .................................................................................................................. 14

3. National AMR Integrated Surveillance System ............................................................................................................ 15

4. National IPC Program in Human Health and Biosecurity and Biosafety in animal health and food safety ............................................................................................................................................................................................................ 15

5. Antimicrobial Stewardship ............................................................................................................................................................ 15

6. Research ....................................................................................................................................................................................................... 16 1.2 Situational Analysis ........................................................................................................................................................................... 17 2- Strategic Objectives And Priority Areas For Action ............................................................................. 19 2.1 The Strategic Objectives ................................................................................................................................................................. 20

1. Enhance Multisectoral Governance for the National AMR Program ............................................................ 21 Priority Areas for Actions ..................................................................................................................................................................... 21 Challenges and Risks related to Implementation of Objective 1: Governance ...................................................... 23

2. Enhance awareness and behavior change ........................................................................................................................... 26 Priority Areas for Actions ...................................................................................................................................................................... 26 Challenges and Risks related to Implementation of Objective 2: Awareness and Behavior Change ...... 28

3. Develop Nationally Integrated and Coordinated "One Health" AMR & AMC Surveillance Systems .................................................................................................................................................................................................................... 29 Priority Areas for Actions ..................................................................................................................................................................... 29 Challenges and Risks related to Implementation of Objective 3: Surveillance ..................................................... 30

4. National IPC Program across sectors, Biosecurity & Biosafety in Animal Health and Food Safety.......................................................................................................................................................................................................................... 31 Priority Areas for Actions ..................................................................................................................................................................... 31 Challenges and Risks related to Implementation of Objective 4: Infection Prevention & Control and Biosecurity & Biosafety ........................................................................................................................................................................... 32 4

5. Optimize the Use of Antimicrobial Medicine in Human Health, Animal Health and Other Sectors ....................................................................................................................................................................................................................... 34 Priority Areas for Actions ..................................................................................................................................................................... 34 Challenges and Risks related to Implementation of Objective 5: Stewardship .................................................... 35

6. Promote and Support AMR Research .................................................................................................................................. 37 Priority Areas for Action ........................................................................................................................................................................ 37 Challenges and Risks related to Implementation of Objective 6: Research ............................................................ 39 3- Implementation ......................................................................................................................................................................................... 43 3.1 Budgeting .................................................................................................................................................................................................... 44 3.2 Monitoring And Evaluation (M&E) .......................................................................................................................................... 45 3.3 "One Health" Approach To Tackling AMR ......................................................................................................................... 46 Appendix 1: Governance Structure Operational Plan .................................................................................................................. 48 Appendix 2 Operational plan for Awareness & Education ....................................................................................................... 50 Appendix 3 Operational plan for AMR surveillance ..................................................................................................................... 55 Appendix 4. Operational plan for IPC, Biosecurity & Biosafety ......................................................................................... 61 Appendix 5. Operational plan for Antimicrobial Stewardship .............................................................................................. 63 Appendix 6. Operational plan for AMR research ............................................................................................................................ 68 Appendix 7: Terms Of Reference .................................................................................................................................................................. 69

1. Awareness/Education Technical Working Group ......................................................................................................... 69

2. Antimicrobial Resistance Surveillance Technical Working Group ................................................................... 71

3. Infection Prevention and Control (IPC) Technical Working Group ............................................................... 73

4. Antimicrobial Stewardship Technical Working Group ............................................................................................. 75

5. Research Technical Working Group ........................................................................................................................................ 77 References ...................................................................................................................................................................................................................... 79 5 Foreword Antimicrobial resistance is spreading rapidly due to its’ multisectoral involvement. Microorganisms can move rapidly between humans, animals, agricultural crops, food sources and the environment. Furthermore, resistant genes can transfer between different microorganisms resulting in untreatable infectious diseases. To effectively combat the spread of antimicrobial resistance, a "One Health" approach across all sectors where antimicrobials are implicated in the country is needed. It has an impact on human health, animal health as well as food security and safety. It poses a threat to achieving the Sustainable Development Goals (SDGs) by 2030. The increase in antimicrobial resistance has been driven by the unrestrained use of antimicrobials in human health, agriculture, and animal health globally. In the State of Qatar, the increasing number of antimicrobial resistant infections appearing in the community and healthcare settings continues to represent a looming public health issue. The World Health Organization (WHO) has called on nations to act, increasing national, regional, and global efforts to slow the development of antimicrobial resistance. In May 2014, the World Health Assembly (WHA) adopted a resolution to develop a Global Action Plan on antimicrobial resistance. Healthcare Quality Department (HQD) at the Qatar Ministry of Public Health (MoPH) led the development of a National Action Plan to combat the antimicrobial resistance threat in the State of Qatar in 2018 and was instrumental in the implementation of the plan particularly in the Human health sector. The 2018-2022 National Action Plan called on all stakeholders to support a collaborative and integrated effort to combat antimicrobial resistance through changing practices that have contributed to the development of resistance and implementing new initiatives to reduce the inappropriate antimicrobial use. Implementing the National Action Plan involved many partners and required a high level of cross-sectoral cooperation including human, animal, food and environmental sectors at local, regional and international levels in alignment with the "One Health"Approach to combat antimicrobial resistance. 6 In its first phase, the National Action Plan delivered an effective and sustainable response to antimicrobial resistance in the State of Qatar along with contributing to the regional and global effort. All stakeholders worked together to combat antimicrobial resistance and ensure the continued widespread availability of effective antimicrobials to support delivery of world class human and animal health services. In the first phase, all governmental hospitals and primary care centers and majority of other healthcare facilities implemented antimicrobial stewardship programs. Antimicrobial resistance surveillance system was already established in human health with participation in the Global Antimicrobial and Use Surveillance System (GLASS) reporting on multidrug resistant organisms since 2019. Qatar also enrolled in the Global Antimicrobial and Use Surveillance System (GLASS) antimicrobial consumption (AMC) module and submitted data since 2021. The implementation of the National Action Plan remains to be in early stages. With Qatars' adoption of "One Health" framework, it is expected that significant gains will be made in combating antimicrobial resistance in the coming years. In the next phase of the National Action Plan 2024-2030, Qatar will build on the gains from the first phase in all sectors and continue the cross-sector collaboration in combating antimicrobial resistance as required by the "One Health" Framework. 7 Abbreviation AMR Antimicrobial Resistance AMS Antimicrobial Stewardship AMU Antimicrobial Use AMC Antimicrobial Consumption AST Antimicrobial Susceptibility Testing ESBL Extended Spectrum Beta-Lactamase GCC Gulf Cooperation Council GLASS Global Antimicrobial Resistance and Use Surveillance System GNB Gram Negative Bacilli HAI Hospital Acquired Infection HMC Hamad Medical Corporation HQD Healthcare Quality Department IPC Infection Prevention and Control M&E Monitoring and Evaluation MDRO Multidrug Resistant Organisms MM Ministry of Municipality MOPH Ministry of Public Health MRSA Methicillin-resistant Staphylococcus aureus NRL National Reference Laboratory PHCC Primary Health Care Corporation QU Qatar University SDGs Sustainable Development Goals TWG Technical Working Group UN United Nations WHO World Health Organization 8 Our Vision A healthier Qatar free from antimicrobial resistance threats where antimicrobials are treated as precious resource across all sectors and are used appropriately only when needed. Our Goal To retain existing and develop new national capacities for prevention and control of AMR through a “One Health” approach. 9 Background Antimicrobial medicines such as antibiotics, antivirals, antiprotozoal and antifungals have dramatically reduced morbidity and mortality related to infectious diseases in both humans and animals. They contributed to saving millions of lives around the world and helped advance medical, dental and surgical practices since the discovery of penicillin in 1928. Resistance to these antimicrobials was recognized almost as soon as antibiotics were discovered. Today, antimicrobial resistance is reversing the gains of the past eighty years, with many important drug choices for the treatment of infections becoming increasingly limited, expensive, and, in some cases, non- existent. The Centers for Disease Control and Prevention (CDC) estimates that each year at least two million illnesses and 23,000 deaths are caused by drug-resistant bacteria in the United States alone. Moreover, antimicrobial resistance also threatens animal health, agriculture, and the economy. The global uncontrolled use of antimicrobials in the human and animal health and in agriculture has augmented the resistance emergence. The poor adherence of healthcare providers to infection control practices, particularly in low resource settings, contributes to transmission of multidrug resistant organisms (MDROs) in the healthcare settings. The lack of essential primary healthcare systems in some settings and legislations on the prudent and responsible use of antimicrobials is also a concern. Furthermore, the prevalent and sometimes unsupervised use of antibiotics in animal health sector adds to the burden of MDROs particularly in food producing animals. In addition, some specific factors have been linked to the emergence and spread of AMR in States Countries of the Gulf Cooperation Council (GCC) including the State of Qatar, this includes heavy international travel due to the large population of expatriate workers and high turnover (where travel is a known risk factor for acquiring and spreading AMR). A significant AMR burden has been described in the GCC countries including Extended Spectrum Beta-Lactamase (ESBL) producing bacteria, Carbapenemase-Producing bacteria, Pan Drug Resistant Gram-negative bacilli (GNB), as well as multidrug-resistant tuberculosis. Between 60% and 90% of Klebsiella pneumoniae isolates are ESBL producers, which is associated with up to 40% mortality. Additionally, 60%— 90% of Acinetobacter causing ventilator-associated pneumonia were shown to be resistant to most tested antibiotics, including Carbapenems, with significant negative clinical impact (Balkhy et al., 2016). 10 Looking at the resistance patterns in the State of Qatar, Methicillin-resistant Staphylococcus aureus (MRSA) prevalence did not present any significant change from 36% in 2009 to 36.5% in 2022 among hospitalized patients. On the other hand, the prevalence in the community showed a dramatic increase during the same time from 26% to 34.3%. Gram-negative Extended Spectrum Beta Lactamase (ESBL) producing E. coli increased from 32% to 58.2% of total E. coli infections between 2012 and 2022 with marked increase in the detection of Carbapenem- resistant Enterobacteriaceae. The first Qatar National Action Plan (NAP) to combat AMR was developed and launched in 2018. The NAP aimed to ensure the continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them. To effectively tackle the growing threat of AMR, Qatar adopted a “One Health” approach to combating AMR including human health, animal health, food safety, agriculture, and environmental sectors. The plan is aligned with the WHO Global Action Plan on combating AMR, the Strategic Plan for Combating AMR in Gulf Cooperation Council (GCC) states, and the National Health Strategy (NHS). The following section will display some of the achievements performed thus far in the implementation journey of the NAP 2018-2022. In this phase of the plan (2024-2030), Qatar remains committed to tackling antimicrobial resistance in humans, animals, food, and the environment as a priority and under a "One Health" approach with increasing cross sector collaboration between human health, animal health, food, agriculture, and the environmental sectors, locally and nationally to contribute to reducing the global burden of the problem. Emphases will be placed on establishing national integrated AMR Surveillance System across all sectors, expanding AMR surveillance in human health to include semi-government and private healthcare facilities, and establishing antimicrobial consumption (AMC) surveillance system in human health and animal health. Another top priority will be to create a national agenda for AMR research across all sectors. 11 Summary of Achievements and Situational Analysis 1.1 Summary of Achievements of Qatar NAP to Combat AMR (2018-2022) The NAP to combat AMR in Qatar (2018-2022) had 5 objectives considering its’ alignment with the Global Action Plan to combat AMR. We will state some of the achievements under each objective. We also succeeded in establishing sections of the governance structure which we will cover here.

1. Governance Structure ‫ ـ‬A National AMR Committee was established by a ministerial decree in 2019. The committee is multidisciplinary and meets regularly each quarter. There are clear terms of reference to the committee and meeting minutes are regularly circulated to the members after each meeting with an action log to monitor implementation of the plan. ‫ ـ‬Five different technical working groups (TWGs) were formed equivalent to the 5 objectives of the plan to manage the implementation of the plan. i. Surveillance TWG meets regularly. ii. Stewardship TWG meets regularly. iii. IPC TWG is functional through the implementation of the national IPC program run by MOPH together with stakeholders from the human health sector. iv. The awareness TWG and research TWG were established with some achievements related to conducting awareness and education activities across the year in addition to conducting a couple of research studies. ‫ ـ‬The Coordinating Center is represented by the National IPC & AMR team that is running the activities of the program at the human health sector nationally, however lacking representation from other sectors. ‫ ـ‬Details will follow below on the achievements of each TWG.

2. Awareness, Education and Behavior Change ‫ ـ‬The State of Qatar is regularly participating in the WHO annual “World AMR Awareness Week” since 2015. Activities include live education sessions about AMR awareness, social media messages, distribution of educational material at healthcare facilities, newspaper articles, and participation in the “GO BLUE” campaign by lighting major landmarks in blue to increase the visibility of the campaign. ‫ ـ‬Education sessions are provided to hospitals and primary healthcare sector about antimicrobial consumption surveillance and the WHO DDD/ATC methodology. ‫ ـ‬The healthcare facilities conduct their own education/training sessions to their staff related to the appropriate use of antimicrobials. ‫ ـ‬A study was conducted at some primary healthcare centers to identify barriers and motivators to appropriate prescribing of antimicrobials to tailor improvement interventions accordingly. One paper was already published, and work is underway to formulate the interventions. 14

3. National AMR Integrated Surveillance System ‫ ـ‬AMR Surveillance in Human Health: Qatar enrolled in the WHO Global Surveillance System (GLASS) AMR module in 2019 to submit data on MDROs. So far, Qatar has submitted AMR data for 2019, 2020, 2021 & 2022 including data from all governmental facilities. ‫ ـ‬Antimicrobial Consumption (AMC) Surveillance in Human Health: Qatar enrolled in the WHO GLASS AMC module in 2022 and has submitted the 2021 data which included all government hospitals and primary healthcare centers covering 80% of the Qatar inhabitants. Data for 2022 was also submitted and more facilities participated in this submission from the private sector. ‫ ـ‬Surveillance in Plants: The Qatar Ministry of Municipality, Agriculture department is conducting surveillance of antimicrobial residues such as fungicides and bacterial pesticides in agricultural crops. ‫ ـ‬Surveillance in Animal Health: The Department of Animal Resources has recently developed a new electronic system to monitor the number of antimicrobials entering the country every year. The animal health laboratory is currently pursuing accreditation and has a plan to enhance their surveillance systems for antimicrobial resistance and sensitivity testing. ‫ ـ‬Surveillance in Food: the national food safety lab has established a surveillance system for tracing antibiotic residues and AMR pathogens in food products to ensure food safety in local produce as well as imported food. Our national food safety lab is internationally accredited as well.

4. National IPC Program in Human Health and Biosecurity and Biosafety in animal health and food safety ‫ ـ‬In the Human Health sector, we have a well-structured IPC program adopting the WHO core component at national level, a national IPC Committee, national IPC policies published on MoPH website, ongoing training programs, the healthcare associated infections surveillance has started and the service is working closely with other relevant stakeholders. ‫ ـ‬Biosafety and biosecurity in animal health sector is also a critical area for intervention to prevent the spread of diseases among livestock and accordingly reduce the use of antimicrobials. A draft for biosecurity standards by industry for example poultry and dairy industry has been developed. Also, there is a biosecurity auditing system for commercial farms that is being piloted in May 2024.

5. Antimicrobial Stewardship ‫ ـ‬Human Health: o Majority of governmental hospitals and primary healthcare centers (Primary Health Care Corporation Centers, Qatar Red Crescent Centers, and Qatar Energy Centers) and semi-governmental hospitals have well established AMS programs, and majority of private healthcare facilities have also made progress in implementing AMS Programs. o Developed National Key Performance Indicators (KPIs) to monitor the AMS program. 15 o The AMS TWG also prepared a set of reports and a policy to enhance their work. They are as follows:  Antimicrobial Stewardship and Prescribing Policy published on MOPH website. This policy mandates that all healthcare facilities must establish AMS programs in accordance with the WHO Core Element for AMS. It also provides guidance on antimicrobial prescribing.  AMR Surveillance Report 2019-2022.  AMR Surveillance Plan 2023-2030. ‫ ـ‬Animal Health: Significant policies have been formulated and recently approved by the Qatar Veterinary Medical Licensing Board, aimed at restricting or prohibiting the use of antibiotics critically important to human health, including enrofloxacin and colistin. The Department of Animal Resources at the Ministry of Municipality has annual vaccination campaigns to prevent and control endemic animal diseases. ‫ ـ‬Agriculture: The Qatar Ministry of Municipality has made significant gains in establishing best agricultural practices to ensure prevention of antimicrobial diseases in plants, accurate diagnosis, and treatment of bacterial and fungal diseases in plants, reducing the use of antimicrobials unless necessary, and limit the use and regulate the import of antimicrobials that work as pesticides.

6. Research ‫ ـ‬Various academic research centers such as Qatar University, Qatar Biomedical Research Center, Hamad Medical Corporation (HMC), Primary Healthcare Corporation (PHCC) and Qatar Foundation and other academic institutions are actively conducting research on AMR and have published multiple research articles in the last 4 years. ‫ ـ‬Point Prevalence Survey (PPS) on Antimicrobial Use in Hospitals: In collaboration with the WHO-EMRO, Qatar completed its first ever PPS on antimicrobial usage in hospitals. The aim of this study is to estimate the prevalence of antimicrobial use in hospitalized patients and provide a standardized tool for hospitals to identify targets for quality improvement and help in designing hospital antimicrobial stewardship programs. 16 1.2 Situational Analysis Members of the national AMR program at the Healthcare Quality Department (HQD), MoPH in collaboration with the members of the five technical groups have conducted a comprehensive situational analysis of the current status of AMR in the State of Qatar to gain insight into what was achieved, and clarify the nature and burden of the problem in the country, as well as its’ impact at the national level and what would be our next steps moving forward with our next action plan (See Appendix 7). Our current governance structure was revisited and areas for improvement were identified. Assessing the capacity of the country to combat AMR using “One Health” approach was one of the indicators used in the evaluation. AMR detection and surveillance of infections caused by AMR pathogens, biosafety and biosecurity in Infection Prevention and Control (IPC) and Antimicrobial Stewardship (AMS) activities were some of the areas assessed. The Plan is supported by six key strategic objectives that will guide all sectors. The first objective of the Plan is a multisectoral governance structure that is required to coordinate the wide range of implementation plans across multiple sectors. This overarching objective establishes clear accountability lines and helps coordinate actions to combat AMR across all sectors in synergy. Then, the following 5 objectives correspond to the 5 objectives in the global action plan to combat AMR which are briefly related to behavior change, AMR surveillance, antimicrobial stewardship (AMS) in both human health and animal health, infection prevention and biosecurity practices to reduce infection transmission and research. 17 18 The Strategic Objectives 2.1 The Strategic Objectives

1. Enhance the existing multisectoral governance structure for AMR program.

2. Develop nationally integrated and coordinated “One Health” antimicrobial resistance and consumption surveillance systems.

3. Develop and promote interlinked informed national infection prevention and control programs across sectors including IPC in human health and biosecurity and biosafety in animal health and food safety.

4. Optimize the use of antimicrobial medicine in human and animal health and other sectors.

5. Enhance the awareness and change behavior targeting antimicrobial use.

6. Promote AMR research in alignment with National Health Strategy and in partnership with national, regional, and international institutions. Each objective outlines strategic priority areas for action to focus resources and to guide the development of action plans. 1 Multisectoral Governance Structure 2 Integrated AMR Surveillance 3 IPC & Biosafety and Biosecurity 4 Antimicrobial Stewardship 5 Awareness and Behavior Change 6 Research and Innovation Figure 1: The six objectives of the national action plan and how they intersect with each other. Figure 1 shows how the six objectives will create the building blocks for the implementation of this national action plan and how the work in these objectives intersects to achieve synergy. The multisectoral governance structure will drive effective action across all objectives with clear roles and responsibilities at the national level (ministries and government entities) and the local level among providers, academic institutions, communities, farms…etc. to ensure leadership commitment and accountability for implementation of actions in the plan. 20 Then, there are 3 distinct objectives (numbers 2 to 4) that will work simultaneously each in their area to achieve clear activities that contribute to combating AMR such as having an integrated surveillance system (2), preventing infection transmission among humans and animals (3) and promoting the judicious use of antimicrobials (5). The two remaining objectives related to raising awareness and behavior change (5) and research and innovation (6) will be operating across all the previous objectives to enhance their implementation and improve the sustainability of improvements/interventions achieved by these objectives while identifying innovative ideas to tackle the problem.

1. Enhance Multisectoral Governance for the National AMR Program Priority areas for actions: 1.1 Enhance the existing governance structure to help better coordination of the work in synergy across all sectors. 1.2 Dedicate sustainable funding for combating antimicrobial resistance in all sectors. 1.3 Develop, implement and regularly report on the sector-specific plans. 1.4 Maintain and expand collaboration between stakeholders across all sectors to allow for a nationally coordinated "One Health" approach to combating antimicrobial resistance. 1.5 Monitor and review legislations and policies relevant to antimicrobial usage and resistance. Leadership and governance are required to coordinate the wide range of implementation plans across multiple sectors. This requirement necessitates creating a governance structure that helps coordinate the work in synergy. It is crucial that AMR is steered at a high-level multisectoral political platform with decision making authority to facilitate official launch and oversee the implementation of the National Action Plan on AMR. Endorsement of the plan from the Council of Ministers, after endorsement from MoPH leadership structure, is critical to the successful implementation of the plan. The multisectoral interministerial AMR Board is yet to be established and become functional. It will have a critical role in engaging other sectors on actively writing the plan and committing to its’ implementation. This board can also be part of the National "One Health" Framework governance structure. We will explore different ways for either establishing this board or utilizing already existing boards where the scope of the program can be added to their functions, where deemed relevant. The multisectoral AMR Board will coordinate the work among all the relevant ministries (MoPH, MME, Finance, Agriculture, Economy & Commerce, Education, Ministry of Information and Communications Technology), Media, Academic Institutes, and other relevant stakeholders. The multisectoral AMR Board will show leadership and support across the relevant government sectors and will oversee the implementation of the AMR plan through regular reports, facilitate endorsing regulations, and making decisions. 21 The National AMR Committee should be reporting to the National multisectoral AMR Board through the National AMR Coordinating Center. The committee will be also receiving reports from the Technical Working Groups working on the strategic objectives. The different technical working groups (TWGs) will have to continue meeting regularly. The terms of reference (TORs) of the TWGs will be developed and agreed on, as part of enhancing their performance. Also, the membership of all groups will be reviewed to ensure complete representation of all relevant sectors. As per the TORs for these TWGs, they will be looking into further development of detailed implementation plans for their objectives and monitor the implementation to provide regular reports. The members are also responsible for the implementation of the activities in their relevant organizations. The MoPH will lead the coordination of the program with all relevant stakeholders and host the National AMR Coordinating Center. The National AMR Coordinating Center is the small group that links the governance structure with each other. The members of this group were identified in the first NAP as the national AMR focal points for human health, the national AMR focal points for animal health and the AMR team working at Healthcare Quality Department (HQD). This group was responsible for coordinating all the activities that were executed thus far to develop the national action plan. Their role is instrumental to the program, as they coordinate communication channels up and down the governance structure. Currently, this group is only made up of human health sector focal point and the team working at the Healthcare Quality Department. We need to have representation from the other relevant sectors to improve the performance of this center and achieve better engagement from all sectors. Roles and Responsibilities Each Ministry/Government entity and provider and academic institution will be accountable for the achievement of activities, outlined in this plan, of which they are the lead. Their responsibilities will also include monitoring progress quarterly and contributing to the development of an annual progress report. 22 Challenges and Risks related to Implementation of Objective 1: Governance Sector Risk Existing Controls / Mitigation Strategy Opportunities Human Patients In human health, • Identify the right audience such as Sector and and public there are patient patients and family for human health Animal are not representation on and farm owners for animal health and Sector represented multiple committees so on. in the such as National • Establish mechanisms for the governance Clinical Guidelines engagement of the target audience structure of development, into the governance. For example, add the program. National Healthcare patient/public representation to the Hence, the Quality Committee, National AMR committee and all the program is however these technical working groups. unable to committees feed capture their indirectly into the • Ensure that their input is incorporated input into work of the National into the plans and interventions of the the program AMR Program. AMR program. governance. • Link with other National Programs that have patients’ representatives such as the Patient and Family advisory Board when established to involve them in the AMR program. • Organize industry-specific meetings, workshops, and forums where representatives from commercial farms and intensive farming operations can voice their concerns, suggestions, and feedback. This can include input on practical challenges, economic considerations, and operational insights. • Provide incentives for example financial or subsidies, or recognition programs for farms that adopt best practices in antimicrobial stewardship. 23 Sector Risk Existing Controls / Mitigation Strategy Opportunities All Lack of The governance • Establish the highest tier of coordination structure in the plan governance at the ministerial level among has the requirement with clear communication channels, stakeholders for multisectoral regular meetings, and designated particularly representation leadership roles. at the at the Council of ministerial Ministers level to • Add members from the other level. support decision relevant sectors to the national making and facilitate coordinating bureau and TWGs with implementation at all communication channels, regular relevant sectors. meetings, and designated leadership roles. • Harmonize policies and regulations across ministries to avoid conflicts and duplication and conduct comprehensive reviews of existing policies to identify and resolve inconsistencies. • Develop a detailed stakeholder engagement plan that includes regular high-level meetings, and progress reports. Clearly outline the roles and responsibilities of each stakeholder in the governance structure. 24 Sector Risk Existing Controls / Mitigation Strategy Opportunities All Ensure • There is some • Write a business case and secure financial funding to some funding approval through the commitment of the AMR governance structure to facilitate the from program activities implementation of the program. government. at the national • Conduct a comprehensive cost- level and facility benefit analysis to demonstrate level in human the long-term economic benefits of health sector. AMR control. This business case will However, there facilitate dedication of funding to the is no accurate implementation activities of AMR in costing of all all sectors. the necessary activities. • Each sector needs to write their own business case to submit to their • Some facilities management with support from the struggle governance of the National AMR to identify Program to allocate funding to AMR. dedicated, sufficient funding • Develop a detailed funding proposal for their local highlighting the economic impact of programs. AMR ensuring equitable distribution of resources based on need and • Dedicated impact. funding for AMR at other sectors • Develop sustainable financing models, is unclear and such as AMR trust funds. questionable. • Promote the integration of AMR funding into broader health and development programs. Human Ensure • Currently the • Ensure that the system allows access Health Universal Public Health to healthcare to all residents in Qatar. Access Services cover • Address waiting time issues as it has to Care both nationals direct impact particularly on infectious particularly and residents diseases management. with the with varied Health degree of Insurance funding. Scheme. 25

2. Enhance awareness and behavior change Priority areas for actions: 2.1 Develop and implement AMR multimodal programs for advocacy, education, awareness and behavior change in various target groups. 2.2 Develop and promote local, regional, and international partnerships for AMR education, awareness, training, and behavior change. 2.3 Financial commitment to supporting AMR Awareness. Enhancing awareness, understanding and behavior change regarding AMR are essential to the Plans’ success. In addition to the "One Health" stakeholders across all sectors, engaging all members of the society will be key. Effectively communicating the threat of AMR, providing education and awareness of threat are vital in empowering communities to take ownership and share responsibility. For effective implementation of these objectives, developing the governance structure to support awareness regarding AMR is key. This could be achieved through enhancing the work of the multi-sectoral National Technical Working Group for AMR awareness and education. Through this group, we will build partnerships with relevant stakeholders with clear responsibilities and accountabilities in government, semi government, and private sectors and include a focal person in each sector to ensure accountability to policy dissemination & compliance. We also need to ensure that there are members from the other technical working groups to represent their groups’ objective and ensure that the education and behavior change interventions related to their objectives are included in the agenda of the education group for example education on AMS, IPC education, biosafety education…etc. The technical working group will assess the knowledge gap about AMR and related topics in all relevant sectors and the community and define priorities and areas for action. This will require creating tools to gather, analyze and report the results to stakeholders and tailor behavior change plans accordingly. The tool will allow us to identify behavioral drivers for antimicrobial use and AMR in all the relevant sectors such as food safety, environment, agriculture, human and animal health. We will establish a robust multimodal educational awareness program and communication strategy to empower professionals across all sectors. The program will include awareness educational program (train the trainer, campaigns, workshops) for professionals in all the relevant sectors. Also, one of the activities of this TWG is to work with academia and healthcare providers to incorporate antimicrobial stewardship principles and strategies in undergraduate and postgraduate curricula for medical, paramedical, and veterinary students and any relevant sectors. Facilitating and ensuring access to in-service training including continuous professional development (CPD) on antimicrobial prescribing and AMS for health-care professionals in the country are additional strategies for enhancing understanding and behavior change. 26 Developing and enhancing e-Learning is a tool to improve the outreach of the education to a wide range of audience across all sectors. Enhancing local, regional, and international partnerships for AMR education, awareness, training, and behavior change is essential to improve and enhance education and awareness interventions in all sectors. Using behavioral science and research, we aim to develop national communication strategy and interventions to communicate the threat of AMR to the public and explain the importance of appropriate use of antimicrobials. We will continue promoting AMR Awareness Week annually targeting both professionals and public while trying to widen the target audience to include professionals from sectors other than human health and relevant community members such as farm owners and relevant business organizations. Promoting the use of technology can facilitate sharing knowledge and reliable data and information about antibiotics and AMR. This can be achieved through creating a "One Health" AMR Website to ensure access to reliable information. Creating and sustaining funding for AMR behavioral interventions at national and facility level is important for successful implementation. This will be done through creating and maintaining a joint "One Health" AMR budget at the national level while supporting the facilities to allocate dedicated funding for their AMR activities. 27 Challenges and Risks related to Implementation of Objective 2: Awareness and Behavior Change Sector Risk Existing Controls Mitigation Strategy / Opportunities All Resistance Education and • Utilize behavioral science to to adopt new raising awareness understand specific behaviors and behaviors. campaigns such tailor the interventions accordingly. as WAAW, Qatar • Ensure that the behavioral studies IPC, World Hand are spanning across the relevant Hygiene Day and sectors i.e. in both human health and others. animal health as each of them have different challenges with different set of interventions to address the challenges. • Implement pilot projects to demonstrate the effectiveness of behavior change. • Use multiple communication channels to reach different audiences. Animal Financial Availability of • Provide incentives for example Health barriers subsidies and financial or subsidies, or recognition preventing financial support programs for farms that adopt best stakeholders programs to practices in antimicrobial stewardship from adopting farmers, potential and biosecurity best practices that recommended for public-private reduce the incidence of infection practices, for partnerships. among their flocks and livestock. example farm • Promote cost-effective solutions and owners afraid alternatives to antimicrobials. to lose their livestock to • Promote public-private partnerships infections. to fund AMR initiatives. Animal Conflict of Regulatory • Draft and distribute Professional Health interest among frameworks codes of conduct for veterinarians . veterinarians governing due to their veterinary practice. dual role as healthcare providers and suppliers of antimicrobials. 28

3. Develop Nationally Integrated and Coordinated "One Health" AMR & AMC Surveillance Systems Priority areas for actions: 3.1 Establish the National "One Health" surveillance system that includes all relevant sectors human, animal, food safety and environment. 3.2 Establish National surveillance system of resistance trends and antimicrobial use in human health, based on agreed National surveillance objectives. 3.3 Establish National surveillance system in animal health, food and environmental sectors. 3.4 Establish National Antimicrobial Consumption Surveillance across all human and animal health sectors. 3.5 Build lab capacity to support national AMR surveillance in human health sector, animal health sector and food safety and environment. Establishing a nationally integrated and coordinated “One Health” surveillance system is important in order to establish continuous prospective surveillance of MDROs in Qatar and estimate trends in AMR rates and to detect the emergence and potential spread of MDROs across all sectors. Integrated surveillance data from all sectors will inform programs that formulate guidelines for treatment and prevention of infections and prevention of MDROs transmission and prioritize actions and resources to combat AMR. A multisectoral and multidisciplinary National AMR Surveillance Technical Working Group (TWG) was established in 2019 to oversee the implementation and progress of National AMR Surveillance System and to coordinate implementation of action plans within facilities through the National AMR Committee. Scope, objectives, and terms of reference of AMR surveillance for each sector; human health, animal health, food safety, and environment will be created ensuring they align with the national “One Health” surveillance objectives. Membership will also be reviewed to ensure that all sectors are represented in the TWG. AMR Surveillance in Human health is well established in Qatar since 2019 in the government sector with plans to expand to the private sector 2024-2030. Qatar has also been part of the WHO Global Surveillance System (GLASS) AMR module since 2019 and has since been submitting AMR data including all governmental healthcare facilities. In terms of Antimicrobial Consumption (AMC) Surveillance in Human Health, Qatar enrolled in the WHO GLASS AMC module in 2022 and has submitted the 2021 and 2022 data from the government sector as well as some of the private healthcare sector providers. Next step is to establish national AMC surveillance system that includes all human health sectors (private and governmental) and establish AMC surveillance in animal health and agriculture. Although AMR surveillance systems in other sectors are yet to be enhanced, significant initiatives have been taken by other sectors. For example, the Agriculture Department at the Ministry of Municipality is conducting surveillance of antimicrobial residues such as fungicides and bacterial pesticides in agricultural crops. The Department of Animal Resources has developed a new electronic system to monitor antimicrobial imports entering the country every year. However, 29 more work is needed to describe and understand the antimicrobial supply chain. The national food lab has established a surveillance system for tracing antibiotic residues and AMR pathogens in food products from local produce as well as imported food to ensure food safety. Qatar National Reference Lab (NRL) was established to build laboratory capacity and support national AMR surveillance system in humans, animals, food and environment sectors, and will take an active role in standardizing methods. The NRL will help to establish integrated "One Health" AMR surveillance system that will unify AMR data across all sectors. The NRL will also establish and develop a national quality assurance program to improve current laboratory capacity, and support training program for laboratory staff for performing and interpretation of antimicrobial susceptibly testing (AST) and AMR. Representatives from this group will join the education TWG and research TWG to ensure education/building capacity and research in the area of surveillance is addressed. Challenges and Risks related to Implementation of Objective 3: Surveillance Sector Risk Existing Controls / Mitigation Strategy Opportunities Health Sector Inappropriate • HMC lab • Develop a comprehensive use of which acts as the diagnostic stewardship diagnostics reference lab for AMR program to support which could be is CAP accredited and appropriate use of diagnostics, over-use, under- has external quality with standardization of use or misuse. assurance systems. methods and a training Also, lack of • There are program to multidisciplinary standardization multiple accredited teams of clinicians to ensure of methods labs in the country. having an impact on clinical of testing management of patients. (diagnostic stewardship). Health sector Lack of feedback Sporadic Clinical • Regular clinical audits that can on prescribing audits performed be facilitated electronically behaviors in some healthcare where feasible. The audit among clinicians. organizations. results to be fed to the relevant clinicians as deemed appropriate to enhance improvement of prescribing behaviors. Health sector Point of Care POCT is available • Ensure the availability of testing (POCT) only in some of highly sensitive and specific is under utilized. the healthcare POCT at all organizations as organizations and deemed necessary. Improve yet not necessarily the workflows to facilitate its utilized fully. successful utilization. 30

4. National IPC Program across sectors, Biosecurity & Biosafety in Animal Health and Food Safety Priority areas for actions: 4.1 Enhance governance and multisectoral commitment to infection prevention and control (IPC), biosecurity and biosafety. 4.2 Enhance and promote cross-sectoral multidisciplinary national IPC program and biosafety /biosecurity across all sectors in Qatar. Infection prevention and Control (IPC) practices comprise an important aspect in controlling the spread of Multidrug Resistant Organisms (MDROs), preventing MDROs transmission in healthcare settings between patients and healthcare workers and from community to healthcare facilities. However, IPC practices are not only required in healthcare settings. They are crucially important to prevent the transmission of MDROs between livestock animals and farmers/ owners, or between companion animals in the same herd or through food chain. Evidence based IPC programs are required across all settings, recognizing higher risk areas. Surveillance data and research are crucial in development and implementation of effective interventions and approaches in IPC. Effective infection prevention and control in human health, animal health, environment as well as effective biosecurity and biosafety measures in animal health and food production help reduce the spread of infections in general with reduction in the need to use antimicrobials. It also reduces the transmission of infections caused by MDROs thus reducing the burden of AMR. Qatar launched the national IPC program and IPC Task Force in 2016. Majority of healthcare facilities in the country have well established comprehensive IPC programs. In the next phase of the plan, we will enhance governance and multi-sectoral commitment to IPC, biosecurity, and biosafety. Currently there is a National IPC Technical Working Group (TWG) that has multisectoral membership. The Plan will aim to strengthen a formal organizational structure to ensure proper implementation of infection prevention and control policies and strategies at national level as well as at the organizational level. This can be achieved by continuing to enforce national policies and guidelines including high policy statement, ensuring that sufficient human and financial resources are available, enhancing engagement of all categories of health care groups, with multidisciplinary representation, accountability from leadership and support from organizational and departmental level, enhance partnerships with relevant stakeholders with clear responsibilities and accountabilities in both public and private sector. We will also promote the collaboration of other departments at MOPH to enhance their role in improving the adoption of IPC policies such as Department of Healthcare Professions, Occupational Health and Safety Department, Facility Master Planning, Healthcare Facilities Licensing. Also, working with Environmental Health and Waste Management to ensure that there are safe systems in place for collection, storage, transport and final disposal of healthcare waste. There is also a need to improve implementation of biosecurity by updating the biosecurity regulations, promoting compliance to biosecurity standards, creating awareness and education programs about biosecurity and animal health among farm workers, and developing a monitoring and evaluation framework to measure the effectiveness of enforcement of these regulatory measures. 31 Enhancing implementation of biosafety measures is also a top priority. This will be achieved by developing the required policies and control measures for ensuring biosafety in the different settings, defining all the organizations which must follow the policies and implement the control measures. Challenges and Risks related to Implementation of Objective 4: Infection Prevention & Control and Biosecurity & Biosafety Sector Risk Existing Controls / Mitigation Strategy Opportunities Health Sector Lack of patient The public is one • Add patient representative to involvement of the target the committee members and in the IPC audiences in all the liaise with the Patient & Family Committee. IPC campaigns, but advisory board once established this is usually a one- to get their engagement in the way communication different plans and activities of rather than active the program. involvement. • Develop mechanisms for regular feedback from patients to improve IPC practices and communication. Health sector Vaccine There are multiple • Work with the vaccination hesitancy national vaccination department to tailor messages considering campaigns and great to the target audience to that vaccination coverage. improve vaccine uptake . vaccination • Use data-driven insights will reduce the to understand barriers to need to use vaccination and develop antimicrobials. targeted educational campaigns. • Engage community leaders and healthcare professionals in promoting the benefits of vaccination. Health sector Disposal Currently, there is no • Develop regulation and of unused clear advice on how system for disposal of unused antibiotics is to dispose of unused antimicrobials at the healthcare not regulated. antimicrobials. facilities and the public. 32 Sector Risk Existing Controls / Mitigation Strategy Opportunities Animal Health Insufficient Basic biosecurity • Update biosecurity guidelines Biosecurity guidelines and to include the latest best Measures. practices are in place. practices and ensure they are Regular health comprehensive. inspections of • Create online courses and livestock. resources that are easily Limited educational accessible. resources and • Conduct regular on-site training occasional workshops. and field demonstrations to show practical application of biosecurity measures. • Establish certification programs for farms and individuals who complete biosecurity training. • Conduct regular audits and reviews to ensure adherence to protocols and identify areas for improvement. • Utilize technology such as electronic monitoring systems and automated data collection tools to enhance tracking and reporting. 33

5. Optimize the Use of Antimicrobial Medicine in Human Health, Animal Health and Other Sectors Priority areas for actions: 5.1 Ensure Uninterrupted access to high -quality antimicrobial medicines. 5.2 Improve and measure appropriate use of antimicrobial agents in human health. 5.3 Ensure adequate access and prudent use of antimicrobial agents in terrestrial and aquatic animals and agriculture. 5.4 Enhance utilization of technology to support improvement in AMS practices and activities (decision support systems). 5.5 Ensure adequate funding and resources for AMS activities. Overuse and misuse of antimicrobials is shown to amplify AMR. Therefore, efforts must be made to limit antimicrobial use judiciously through implementation of effective antimicrobial stewardship practices. As a first step to foster conservation of antimicrobials in Qatar, non-prescription use of antimicrobials in humans was banned in 2002. Similar legislation is also present in animal health sector however, monitoring and enforcing implementation is required. Similar measures need to be taken in other sectors. The uninterrupted access to high quality antimicrobials in humans overall and especially narrow spectrum first line agents used for treating common infections is extremely important to minimize the misuse and overuse of broader spectrum agents. Also, the availability of last line agents for treatment of MDROs is important because they can be lifesaving in the vulnerable population. Qatar has regulations that ensure continued access to high quality antimicrobials and a quality management system for supply chain. Implementing an electronic track and trace system paired with an e-prescribing system will help track antimicrobials from the point of entry into the country to the point of dispensing at the community pharmacies and all healthcare facilities. Implementing antimicrobial stewardship (AMS) programs in all sectors is essential for ensuring appropriate use of antimicrobials and reducing AMR in all sectors. A multisectoral and multidisciplinary National AMR Stewardship Technical Working Group (TWG) was formulated in 2019 to oversee the progress of AMS programs at facilities and to coordinate implementation of action plans with all sectors through the National AMR Committee. Clear and specific scope, objectives, and terms of references for the group for each sector will be created ensuring alignment with the national “One Health” objectives. In human health, majority of hospitals and primary care centers have well established antimicrobial stewardship (AMS) programs according to the WHO core elements for antimicrobial stewardship (AMS). The level of implementation of the core elements varies based on the capacity of the healthcare facilities ranging from planned implementation to full implementation of the components within the six core elements. Currently, AMS programs is mandated by the government through the National AMS policy. Facilities’ leadership will also be required to ensure adequate funding, human and other resources for AMS activities. For monitoring and evaluation of the AMS programs in healthcare facilities, key performance measures were developed and implemented in 2022. 34 Antimicrobial stewardship in other sectors is still at early stages. In animal health, important policies have been developed and recently endorsed by Qatar Veterinary Medical Licensing Board that restrict the use of critically important antibiotics to human health such as enrofloxacin and colistin. Annual vaccination campaigns are conducted to prevent and control endemic diseases in animals/livestock. The animal health department will develop antimicrobial prescribing guidelines that are industry specific; for poultry, cattle…etc. This should be followed by a program for implementation to monitor antimicrobial use and antimicrobial resistance at the farms. We need to create a collaborative mechanism for animal industries to identify common research, development and extension priorities for the effective monitoring of antimicrobial use and surveillance of AMR to inform stewardship actions that meet Qatars’ animal health and market access needs, without impacting food safety or human health. The Department of Agriculture at the Ministry of Municipality has established best agricultural practices to ensure prevention of infectious diseases, accurate diagnosis, and treatment of bacterial and fungal diseases in plants to reduce the use of antimicrobials unless necessary and limit the use and regulate the import of antimicrobials that work as pesticides. In the next phase of the plan, we will build on the achievements, enhance antimicrobial stewardship efforts in human health, build capacity in other sectors under the Qatar “One Health” framework. Challenges and Risks related to Implementation of Objective 5: Stewardship Sector Risk Existing Controls / Mitigation Strategy Opportunities Health Sector Inappropriate None • Develop policies and antibiotic legislations to regulate any promotion. promotional activities. Health sector Appropriateness -National Clinical • Behavioral studies. of prescriptions. Guidelines and • Audit system at physician facility guidelines level. exist to provide guidance on the use of antimicrobials. Health sector Integrate None • Implementation: universal IT AWaRe system. classification in • Clinical Audits. the guidelines and prescription system. 35 Sector Risk Existing Controls / Mitigation Strategy Opportunities Animal Sector Insufficient • Developing standard education and prescribing guidelines and training on AMR conducting regular training and stewardship sessions for veterinarians and practices for farmers. veterinarians, • Continuous professional farmers, development programs and and other accessible resources help keep stakeholders. stakeholders informed about the latest best practices. • Promote the use of advanced diagnostic tools to reduce unnecessary antimicrobial use. • Institutionalizing AMS practices in training programs and securing long-term funding commitments are crucial steps. Animal Sector • Insufficient Availability of • Provide training and resources data on fragmented AMR to build the capacity of antimicrobial data from clinical personnel involved in AMU use and samples in the and AMR surveillance. resistance National Veterinary • Collaborate with the National patterns Laboratory. AMR Monitoring Center at hinders HMC for standardizing testing effective protocols, data and forms. policy- making and • Assess current practices practice. and existing data collection systems. We need to • lack of survey large-scale farms to trained understand current AMU personnel practices and data availability. to collect, Implementing the data analyze, and collection protocol on a limited interpret number of large-scale farms is AMU and suggested. AMR data. 36

6. Promote and Support AMR Research Priority areas for actions: 6.1 Establish the multisectoral TWG for AMR research and innovation with clear terms of reference. 6.2 Promote AMR research in partnership with national, regional and international organizations and institutions. Although over the last four years, various academic research centers, such as Qatar University (QU), Hamad Medical Corporation (HMC), Weill Cornell Medicine – Qatar and Qatar Foundation, have actively been conducting research on AMR and have had multiple publications, there is no clear national agenda for AMR research. The first step to promote AMR research will be to establish a governance structure by creating a multisectoral National AMR Research Technical Working Group (TGW) with clear terms of reference. The TWG will conduct a situation analysis by reviewing and assessing data generated by studies performed in the field of AMR in the State of Qatar and published in international peer-reviewed journals during the period 2018-2024. They will be evaluating the potential relevance of the data these studies may generate for Qatar, and analyze existing policies and guidelines related to AMR to assess their degree of alignment with the local epidemiological data generated by relevant publications between 2018 and 2022. The TWG will also identify research gaps and develop a priority National research agenda for AMR with specific research topics and questions to be addressed in the timeframe 2024-2030 and identify the most suitable research groups to conduct studies within the priority research topics. The goal should not only be to fill a knowledge gap but also to produce novel approaches for AMR diagnosis, treatment and prevention. MOPH will ensure the allocation of resources and funds that enable research groups to perform priority research projects in AMR and ensure that the data produced by these studies can be translated into practice. Encouraging inter-sectoral partnerships, data sharing, and networking among national, regional and international research community on AMR using “One Health” Approach will be key. This can be done through creating a data sharing national repository-platform where data sets, presentations, and publications are accessible for all research groups and any relevant stakeholders who can utilize the data to improve practice to enhance collaborative endeavors, encouraging and supporting research groups to participate in regional and international collaborative research projects, and fostering and support local research groups to participate in local, regional, and international events on AMR and relevant topics. Some of the research studies that were identified as priorities for this NAP were Point of prevalence surveys to measure antimicrobial consumption, clinical audits to assess compliance with guidelines, behavioral change studies to analyze antimicrobial prescription patterns, observational studies 37 aimed to characterize multidrug-resistant microorganisms using whole-genome sequencing, quasi-experimental studies aimed to assess the impact of diagnostic stewardship interventions and quality improvement studies. A clear national agenda for AMR research will address the need to prioritize AMR research and research translation activities to ensure gaps in the evidence are addressed and to encourage collaboration and information sharing, both nationally and internationally. Strong research in AMR and related topics and national systematic coordination of research effort are essential to advance the discovery of new therapies and diagnostic technologies to better prevent infectious disease, treat resistant infections and support the development, refinement, and implementation of evidence-based practices to limit the emergence and spread of antimicrobial resistance. 38 Challenges and Risks related to Implementation of Objective 6: Research Sector Risk Existing Controls / Mitigation Strategy Opportunities All Sectors Build capacities for Currently, there are • Collaboration with implementing AMR multiple AMR research academic institutions. research. studies conducted • Expertise, cooperation and however they don’t funding. necessarily feed into the national AMR program. All Sectors Develop a national • Collaborate with academia, agenda for AMR research institutions and research. providers such as HMC, PHCC. • Collaborate with relevant stakeholders in other sectors . • Establish a national AMR research database. • Secure fundings. All Sectors Poor coordination Currently, some research • Promote interdisciplinary and communication institution includes research to address among disciplines multidisciplinary research AMR, highlighting the can lead to in both human health and importance of collaborative fragmented efforts animal health (Biomedical approaches. and duplication of Research Center – Qatar research. University). All Sectors Promising • Utilize research findings to laboratory close the knowledge gaps findings may not and improve practices. be effectively • Conduct education and translated into training programs for clinical settings or healthcare providers, veterinary practice veterinarians, and farmers or farms. on the latest research findings and their practical applications. 39 Operationalizing The Plan The Plan outlines the framework to guide the implementation of a national coordinated approach to addressing the threat of AMR in the State of Qatar. There is a wide range of activities already taking place based on the situation analysis: regulatory restriction of antibiotics prescription and dispensing, national AMR IPC program, surveillance of MDROs across all sectors, participation in global AMR and AMC surveillance, antimicrobial stewardship programs in human health, and surveillance of MDROs in some healthcare facilities. However, there is still need of the concerted efforts at the national level of all relevant sectors to work synergistically to achieve the goals and objectives set in this plan. The next steps are to strengthen cross sector collaboration and establish a framework for accountability of all "One Health" stakeholders in fighting AMR in Qatar. Successful implementation of the interventions and activities in the National Action Plan requires sustained, coordinated, and mutually reinforcing efforts of all stakeholders, including healthcare providers, healthcare leaders, veterinarians, agriculture industry leaders, policymakers, and patients and supported by the notion of “Health in All Policies” that Qatar National Development Strategy and the National Health Strategy promote for. Accordingly, there is a need for national policies that integrate the necessary actions across all the relevant sectors that can be endorsed at the highest level of governance (inter-ministerial board) which will enable successful implementation of the plan. The operational plan outlining the Strategic Priorities, Secondary Objectives, and Activities identified were finalized after deep situation analysis by multisectoral stakeholders across the country. In the next phase of the Plan, it will be ensured that all five technical working groups covering the five Strategic Objectives will help coordinate the activities and track their progress. The operational plan will be reviewed annually against its progress indicators identified in the Monitoring and Evaluation (M&E) framework (to be developed). 40 41 Implementation Budgeting In the human health sector, there is budget for the National AMR program that is allocated by MOPH and the National Health strategy (2024-2030) and will continue to support AMR activities at the national level. Also, each healthcare facility is required to ringfence budget dedicated to the implementation of the NAP to combat AMR at the facility level. Funding for AMR in other relevant sectors is required for successful implementation of the program. To implement national action plans (NAPs) on antimicrobial resistance (AMR), across other sectors, a clear approach to planning and budgeting the NAP on AMR is required. A business case to understand how much activities will cost, what is already being funded, and how to leverage additional funding can help estimate the necessary funding required. Knowing the gaps will help to mobilize extra resources to fill those gaps to allow for successful implementation of the AMR prevention activities. 44 Monitoring And Evaluation (M&E) Monitoring and Evaluation (M&E) is an integral part of the NAP. The need for a comprehensive system to monitor and evaluate the NAP is important to track progress, prioritize actions, allocate resources appropriately, and identify learning to improve implementation plans to address the country’s efforts to tackle AMR. It is expected to be part of the implementation plans. We will include process indicators, output indicators, outcome indicators and impact indicators. They are also tailored to the country’s priorities and national and local interventions. Monitoring Monitoring is defined as a continuous process of collecting, analyzing and reporting specific indicators linked interventions set out to meet specific objectives. Monitoring these KPIs will inform decision makers on the progress of implementation of these specific interventions and how we approach meeting our objectives, whether we are on track, on time and within budget. M & E should also cover the progress in all the relevant sectors based on the interventions and the objectives of the plan. Accordingly, indicators will be monitored in human health, animal health, food safety, agriculture and environment. Evaluation “Evaluation is the objective and systematic assessment of an upcoming, ongoing or completed project, program, policy or strategy, its design, implementation and results with a view to assessing whether intended objectives have been achieved. The criteria utilized are relevance, effectiveness, efficiency, coherence, impact and sustainability to determine the level of achievement. (Molund et al., 2004 sited in Guidance to facilitate monitoring and evaluation for Antimicrobial resistance national action plans). A subgroup will be formed to develop the M & E plan with all the relevant stakeholders. There are specific steps for the development of the M & E plan that are outlined by WHO which will be followed. 45 "One Health" Approach To Tackcling AMR Success and sustainability of the Plan depends on strong collaboration across all "One Health" sectors due to the complex nature of the problem AMR poses. Establishing clear roles and responsibilities for all sectors and promoting accountability and ownership of the sector specific Strategic Priorities, from conducting the activities and interventions to establishing and performing periodic monitoring and evaluations of these activities, will be key to successfully combatting AMR. In the next phase 2024-2030 of the Plan, the aim will be to stay committed to tackling antimicrobial resistance in humans, animals, food, and the environment under a "One Health" approach with increasing cross sector collaboration between human health, animal health, food, agriculture, and the environmental sectors, locally, nationally, and globally. Priority interventions have been identified across all strategic priorities in the Plan. Promoting AMR awareness among professionals is the most important step to ensure best practices in antimicrobial use, antimicrobial stewardship and IPC measures across the human, animal, food, and environmental health sectors. Public engagement through community outreach campaigns will also be important in increasing awareness among the Qatar population about AMR that will help them understand the threat posed by AMR, the benefits, and risks of taking antimicrobials and using them only when needed and promoting personal and food hygiene and infection control in their daily lives. In the human health sector, majority of healthcare is delivered at governmental healthcare facilities. Strengthening and sustaining antimicrobials stewardship and IPC programs across all governmental healthcare facilities is extremely important in ensuring appropriate use of antimicrobials, preventing infections, and curbing AMR. Strong leadership support from hospital administration such as dedicating financial and human resources to AMS and IPC programs will be key to successfully delivering the best and safest patient care. The private healthcare sector is rapidly growing in Qatar and is expected to grow more in the coming years. Majority of private healthcare facilities have implemented IPC programs and the national IPC team continuously supports them in training and building capacity. To assess and monitor the burden of healthcare associated infections and surgical site infections, the national IPC team has developed a plan for ongoing HAI and SSI surveillance across all healthcare facilities including the private sector. Stewardship programs, on the other hand, are still in early stages in private healthcare facilities. The enforcement of the Antimicrobial Stewardship and Prescribing policy which mandates all healthcare facilities to have AMS programs will expedite the implementation of AMS programs in the private sector. Special emphasis will be placed on establishing national integrated AMR Surveillance System across all sectors. Efforts will include expanding AMR surveillance AMR surveillance in the human health sector to cover semi-government and private healthcare facilities, establish antimicrobial consumption (AMC) surveillance system in human and animal health, and build microbiology lab 46 capacity in animal health to ensure best laboratory practices with external quality assurance. Establishing and sustaining a national integrated AMR surveillance system across all sectors will be possible after the full activation of the National Reference Laboratory (NRL). The NRL will lead in building and enhancing lab capacity building, establishing, and enforcing standards for all sectors (human health, animal health, food sector and environment) across governmental and private facilities that meet the requirements for global reporting of AMR. Taking into consideration the potential challenges, impact and complexities involved at the administrative level and also at the local industries, monitoring regulations on the restriction of use of all antimicrobials by prescription only in animals will be one of the top priorities. One of the prerequisites of the success of this intervention is to ensure that farmers have adequate access to veterinary services to avoid any negative impact on animal health due to the inability to obtain prescriptions. In addition, requiring a prescription for all antimicrobials might increase the operational costs for farmers and animal owners, due to the need for veterinary consultations. This could have economic implications, especially for small-scale operations. To ease the transition and allow stakeholders to adjust to new practices, a phased implementation approach can be adopted. This will involve gradually rolling out the regulations and conducting pilot programs in selected farms to test and refine the process before nationwide implementation This way, we can ease the transition and allow stakeholders to adjust to new practices. Sustaining best practices established by the Agriculture Department will help prevent infectious diseases, ensure accurate diagnosis and treatment of bacterial and fungal diseases in plants, reduce unnecessary use of antimicrobials, and regulate the import and use of antimicrobials that work as pesticides. Another top priority will be to create a national agenda for AMR research across all sectors. Drafting a "One Health" national research agenda will be essential in linking AMR in all sectors and better understanding the development and spread of resistant organisms to guide us on how to treat and contain them. 47

Appendix 1: Governance Structure Operational Plan Secondary Activities Led By Implementation Objectives 1.1 Enhance the existing governance structure to help better coordination of the work in synergy across all sectors A. Endorse the Finalize and endorse the NAP 2024-2030 National National NAP 2024- and submit to HE – MOPH Minister and 2030 the Executive Board for endorsement Share the approved NAP 2024-2030 with National Regional & IHR to share with EMRO to publish on global WHO/EMRO website B. Activate Identify opportunities to activate the National National the AMR interministerial board either through Multisectoral National "One Health" Program or Inter-Ministerial any other mechanism to enhance the Board governance structure of AMR program C. Enhance the Review the membership of the National National National work of the AMR in light of the latest Ministerial National AMR changes based on Emiri Decree Committee and Develop TORs for the TWGs to enhance National National the TWGs their performance Review the membership of the TWGs to National National ensure multisectoral representation Review the membership of the National National National AMR coordinating bureau to include members from other sectors 1.2 Dedicate sustainable funding for combating antimicrobial resistance in all sectors A. Place the Include AMR program as one of the National National NAP for projects in Qatar National Development combating AMR Strategy in the country's Include AMR program as one of the National National strategic projects in National Health Strategy priorities to ensure funding. Develop a business case for AMR at the Sector Sector specific different sectors to support allocation of specific funds 48 Secondary Activities Led By Implementation Objectives 1.3 Develop, implement and regularly report on the sector-specific plans A. Develop a Develop a comprehensive measurement National National comprehensive system that successfully monitor the monitoring implementation of the NAP at all the and evaluation relevant sectors at the national level framework for Develop a comprehensive measurement Sector Sector specific the NAP actions system that successfully monitor the specific implementation of the NAP at all the relevant sectors at the facility level in all relevant facilities for example healthcare facilities, farms, veterinary…. etc. 1.4 Maintain and expand collaboration between stakeholder across all sectors to allow for a nationally coordinated "One Health" approach to combating antimicrobial resistance A. Work Create local partnerships with academia National, with relevant and research institutions regional and stakeholders Create regional and international international in partnerships partnerships with relevant organizations with collective such as Gulf CDC, EMRO, WHO, Fleming goals Institute, Department for Environment, Food & Rural Affairs (DEFRA - UK), etc. 1.5 Monitor and review legislation and policies relevant to antimicrobial usage and resistance A. Develop and Identify the necessary legislations update policies required to prohibit the inappropriate use and legislations of Antimicrobials across all the relevant as deemed sectors and monitor its’ implementation necessary to combat AMR 49

Appendix 2: Operational plan for awareness & Education Secondary Activities Led By Implementation Objectives 2.1 Develop and implement AMR multimodal programs for advocacy, education, awareness and behavior change in various target groups such as healthcare providers, veterinarians, farmers, the community, food safety sector and decision makers in collaboration with relevant stakeholders) A. Develop the i. Enhance the work of the TWG for MoPH National governance AMR awareness represented by different structure sectors to support ii. Build partnerships with relevant MoPH National awareness stakeholders with clear responsibilities regarding AMR and accountabilities in government, semi government, and private sectors. iii.Nominate a focal person in each MoPH National sector to ensure accountability to policy dissemination & compliance iv. Recruit members from the other MoPH National technical working groups to represent their groups' objective and ensure that the education and behavior change interventions of their objectives are included in the agenda of the education group for example education on AMS, IPC education, biosafety, etc. B. Assess the i. Create tools for data gathering, All National knowledge gap analyzing, and reporting the results to stakeholders about AMR stakeholders and related topics (Deep ii. Create behavior change plan according All National Situational to assessment result and identify stakeholders Analysis) and behavioral drivers for antimicrobial use in define the all relevant sectors (campaigns, behavior prioritieswith change interventions, communication plans relevant and awareness/education materials) stakeholders) 50 Secondary Activities Led By Implementation Objectives C. Establish i. Develop awareness educational programs MoPH/ National a robust (train the trainer, campaigns, workshops) Educational multimodal for healthcare professionals and for Institutions educational animal health, food safety and agriculture awareness professionals program and ii. Develop and implement multidisciplinary MoPH/ National communication team training in the field of AM Educational strategy Prescribing and dispensing for example Institutions physicians, clinical pharmacist, and nurses iii. Include antimicrobial stewardship MoPH/ National principles and strategies in undergraduate Educational and postgraduate curricula for medical, Institutions paramedical, and veterinary students and any relevant sectors iv. Facilitate and ensure access to in-service MoPH/ National training including continuous professional Educational development (CPD) on antimicrobial Institutions prescribing and AMS for health-care professionals in the country v. Strengthen communication and MoPH/ National education initiatives for animal health, food Educational safety and agriculture professionals Institutions vi. Work with media organizations, media MoPH/ National channels, influencers, and community Educational leaders to simplify and promote messages Institutions about AMR as an urgent issue, enhancing awareness and reporting vii. Set national communication strategy MoPH/ National for AMR Educational Institutions 51 Secondary Activities Led By Implementation Objectives viii. Integrate AMR awareness education MoPH/ National program /Campaign for public and cover Educational different sectors (e.g. including AMR Institutions awareness program in school curriculum, all educational institutions), labor camps health centers, Food Industry, agri- business and community) D. Promote i. Promote and upport World Antibiotic MoPH/ all National AMR Awareness Week in all healthcare settings Stakeholders Awareness and public Week ii. Develop joint awareness and coordination of messages that reflect all sectors' objectives/priorities iii. Promote and Support Antibiotic MoPH/ National Awareness Week in animal health, Animal and agriculture and food safety Environmental sectors iv. Endorse a “One Health” AMR MoPH/all National/ Awareness approach Stakeholders International E. Develop i. Develop e-Learning modules for health MoPH National and Enhance professionals in human health and animal e-Learning health about national clinical guidelines ii. Utilize the WHO e-learning module for MoPH/ all National human health Stakeholders iii. Mandate e-learning on AMR and IPC as MoPH National part the National Health Insurance Scheme for clinical staff iv. Monitor compliance with WHO AMS MoPH National Core Element for Education and Training 52 Secondary Activities Led By Implementation Objectives F. Develop a i. Develop resources that promote All National stakeholder appropriate antimicrobial prescribing, in stakeholders engagement & human health care and veterinary settings communication plan to support ii. Conduct behavioral studies within All National the change the community to develop resources stakeholders of behavior that address patient pressure and using the misconceptions. These resources will help “One Health” health professionals, especially general approach practitioners and veterinarians, reinforce key messages about proper antimicrobial use and actions to reduce antimicrobial consumption. 2.2 Develop and promote local, regional, and international partnerships for AMR education, awareness, training and behavior changes. A. Develop i. Develop local, regional, and international Ministries National level robust partnerships to improve and enhance and international partnerships all the interventions of the education, on education, awareness and change of behavior awareness activities in healthcare settings and change of ii. Develop local, regional, and international Ministries National level behavior partnerships to improve and enhance and international all the interventions of the education, awareness and change of behavior activities in animal, food and agriculture settings B. Promote use i. Use technology to facilitate share of data All National of technology and knowledge and change behavior (video stakeholders to achieve conference) vision ii. Standardize and improve the education All National programs (local regional) stakeholders iii. Create a “One Health” AMR website All National to ensure access to reliable sources of stakeholders information on antibiotics and AMR 53 Secondary Activities Led By Implementation Objectives C. Promote i. Conduct KAP research in the field of All National research in the education and awareness and identify new stakeholders field of AMR ways of changing behavior in human health awareness and education ii. Conduct research on the farmers’ All National perceptions and attitudes towards the use stakeholders of antimicrobials 2.3 Financial commitment to supporting AMR Awareness A. Create a 1. Maintain a joint "One Health" AMR Ministries National budget for plans and budgets and mobilize resources AMR program together 2. Facilities to allocate funding for AMR Facilities National awareness campaigns and staff CPD education 3. Allocate funding for AMR awareness Facilities National to Integrate the awareness education program for public 54

Appendix 3: Operational plan for AMR surveillance Secondary Activities Led By Implementation Objectives 3.1. Establish the national “One Health” surveillance system including all relevant sectors human, animal, food AND environmental. A. Establish i. Review membership of the National MoPH National central national TWG for surveillance of AMR to include governance/ all relevant sectors and ensure active structure engagement for “One ii. Define scope, objectives and terms of Health” AMR references of AMR surveillance for each surveillance at sector, human, animal, food and environment MoPH ensuring they align with the national “One Health” surveillance objectives B. Develop i. Set up electronic surveillance center at MoPH National national MoPH to centralize data collection and electronic analysis from all stakeholders and relevant surveillance sectors system for ii. Identify and prioritize the organisms and AMR. relevant antimicrobials that will be reported in each sector iii. Create a national monitoring and evaluation framework for auditing KPI to ensure that surveillance efforts are effectively implemented iv. Participate in regional and global networks and sharing data, so the national and regional and global trends can be detected v. Collect and report dynamic data on antimicrobial consumption in all sectors C. Promote i. Enhance research on integrated AMR MoPH National Research in the surveillance using "One Health" approach field of AMR surveillance ii. Enhance research on AMR trends and MoPH National antibiotics use in humans 55 Secondary Activities Led By Implementation Objectives 3.2 Establish National surveillance system of resistance trends and antimicrobial use in human Based on i. Expand surveillance by identifying and MoPH Facility agreed national assessing the eligibility of new sentinel surveillance sites that will contribute to the national objectives AMR surveillance from public and private sectors including primary care settings, the community and hospital settings iv. Set up and use uniform LIS/reporting template e.g., compatible with WHONET at the coordinating center and participating facilities v. Determine national KPI to ensure that surveillance efforts are effectively implemented vi. Develop a national antibiogram and reporting system including reports/bulletin to inform clinicians and decision makers about emerging trends that could impact public health vii. Design mechanism/alert system to detect and report the newly emerging resistance viii. Develop framework for monitoring and reporting antimicrobial consumption in hospitals and primary care settings to assess appropriateness of use 56 Secondary Activities Led By Implementation Objectives 3.3 Establish National AMR Surveillance System in animal health, and food and environment sectors. B. Publish a i. Determine the organisms list and MoPH Facility list of country associated antimicrobials for surveillance priority and consider WHO recommended list organisms that includes: • E. coli • K. pneumoniae • (High alert A. baumannii • Staph. aureus • Salmonella pathogens) spp • Shigella spp • Neisseria gonorrhea and associated Pseudomonas aeruginosa, Neisseria antimicrobials meningitidis, Haemophilus influenzae, for national Salmonella enterica serovar Typhi and reporting to Salmonella enterica serovar paratyphi A be aligned ii. Update the organism list in response to the with WHO changing incidence of resistant organisms surveillance model iii. Standardize antimicrobial sensitivity testing (AST) and uniform reporting of national pathogens on an annual basis 57 Secondary Activities Led By Implementation Objectives A. Design i. Identify and assess the eligibility of new MoPH for Sector national AMR sentinel sites that will contribute to the food and surveillance national AMR surveillance system from environment sentinel center animal health, food safety and environment Ministry of in both animal sectors Municipality health and ii. MoPH Food Safety lab will provide AMR for Animal food sector and surveillance and antimicrobial residue data to environment the MOPH AMR technical working group in a standard format iii. Enhance laboratory capacity in the animal sector through performing needs assessment and building capacity and capability in the animal health lab iv. Provide AMR surveillance data to the MoPH AMR technical working group in a standard format iiv. Establish a reporting system for sharing the data among the stakeholders and generating data that are internationally comparable and compatible with the "One Health" approach v. Identify the reportable organisms and relevant antimicrobials panel for integrated surveillance in animal health, food safety and environment sectors vi. Review the national regulations for testing food imports and include testing for antimicrobial residues 3.4. Establish National Antimicrobial Consumption Surveillance across all human and animal health sectors. 58 Secondary Activities Led By Implementation Objectives A. Develop i. Develop national standard tools to monitor MoPH and Sector central system and report antimicrobial consumption in Ministry of to monitor human health and animal health, food and Municipality and report agriculture sectors antimicrobial ii. Collect dynamic data on antimicrobial use across all consumption in human and animal sectors sectors, human and animal iii. Update the list of antimicrobials to be health, food monitored on regular basis for surveillance safety sectors according to national and international guideline recommendations iv. Link the resistance patterns to antimicrobial consumption across all humans, animal health, and food sectors v. Link AMR in all animals, food, and environment sectors to the human health 3.5 Build laboratory capacity to support national AMR surveillance system in human health, animal health, food safety and environment/agriculture sectors. A. Establish and i. The National reference lab (NRL) provides MoPH and Sector design National guidance and support to laboratories Ministry of Reference involved in surveillance systems. It aims to Municipality Microbiology adopt national standards and protocols, laboratory for enhancing local, regional, and national each sector capabilities for AMR surveillance. to provide The key functions of the PRL includes an effective Guidance and Standardization (Policies surveillance of and procedures), Reference Functions, AMR training, Data collection and analysis, Assessments of laboratories and research ii. Each national lab will develop and include the AMR surveillance responsibilities in the future iii. Identify the international accredited laboratories/ centers that participate in the surveillance system in human health, animal health, food and environment laboratories 59 Secondary Activities Led By Implementation Objectives B. Establish i. Identify and determine quality assurance MoPH and National and develop a indicators as external proficiency test (PT), Ministry of national quality turnaround time (TAT), benchmarks Municipality assurance ii. Form standard platform for laboratory program to testing methods for anti-microbial improve current susceptibility among participating labs laboratory capacity iii. Develop national guidelines and SOP with emphasis on the reportable national pathogens C. Support i. Provide training or workshops to all sectors MoPH and Sector training human, animal and food in collaboration Ministry of program for with HMC Microbiology lab to standardize Municipality laboratory methods used for AST and AMR surveillance staff on performing and interpretation of AST and AMR 60

Appendix 4: Operational plan for IPC, Biosecurity & Biosafety Secondary Activities Led By Implementation Objectives 4.1. Enhance governance and multi-sectoral commitment to IPC and biosecurity/ biosafety. A. Strengthen I. Continue national policies and guidelines MoPH/ National and a formal including high policy statement Facilities Facility organizational ii. Ensure sufficient resources are available; MoPH/ National and structure to human and financial Facilities Facility ensure proper development iii. Enhance engagement of all categories of MoPH/ National and and use of health care groups, with multidisciplinary Facilities Facility infection representation, accountability from prevention and leadership and support from organizational control policies and departmental level and strategies iv. Initiate IPC product evaluation process MoPH/ National and at the national Facilities Facility level and support and v. Enhance partnerships with relevant MoPH/ National and activate at the stakeholders with clear responsibilities and Facilities Facility organizational accountabilities in both public and private level sector (DHP, Occupational Health, facility master planning, waste management) vi. Ensure that there are safe systems in place MoPH/ National and for collection, storage, transport and final Facilities Facility disposal of healthcare waste 61 Secondary Activities Led By Implementation Objectives B. Strengthen Collaborate with relevant stakeholders, Department National and a formal including farmers, veterinarians, and of Animal Facility organizational agricultural organizations, to develop sector- Resources, structure to specific biosecurity manuals that emphasize MM ensure proper responsible antibiotic use and AMR development prevention and Disseminate the farm biosecurity manuals implementation and provide training to farmers and of Biosecurity stakeholders on their implementation and biosafety measures at the national level and at the organizational level 62

Appendix 5: Operational plan for Antimicrobial Stewardship Secondary Activities Lead Implementation Objectives Organization Level 5.1. Ensure uninterrupted access to high-quality antimicrobial medicines – Primary and secondary and private and Community Pharmacy Network A. Improve i. Review and strengthen national MoPH/ National regulation regulations regarding the use and access to Pharmacy and for access to high quality antimicrobial medicines Drug Control high quality ii. Continue quality management MoPH/ National and antimicrobials system for supply chain management of Pharmacy and Facility in all Qatar antimicrobial medicines Drug Control healthcare facilities iii. Create country essential medicine list MoPH/ National and (EML) for antimicrobials and classify by Pharmacy and Facility WHO AWaRe classification Drug Control iv. Develop and implement National MoPH/ National and Adverse Drug Reporting System to include Pharmacy and Facility monitoring safety of all antimicrobials, Drug Control especially new agents. v. Develop and enforce regulation for MoPH/ National rationing of antimicrobials and distribution Pharmacy and to facilities across Qatar with complete Drug Control transparency of the process vi. Develop a reporting system for issues MoPH/ National related to procurement, access, shortages, Pharmacy and and stockouts of antimicrobial medicines Drug Control B. Activate 1. Introduce an integrated computer MoPH/E- National and implement system across all healthcare sectors Health MoPH allowing pharmacies across the country community to have access to antimicrobial dispensing pharmacy information strategies to avoid overuse and misuse of antimicrobials 63 Secondary Activities Lead Implementation Objectives Organization Level 5.2. Improve and measure appropriate use of antimicrobial agents in health care – AMS in human health. A. Continue i. Maintain and enhance National MoPH National and enhance Antimicrobial Stewardship Technical the National Working Group to promote, coordinate, AMS Program and monitor prudent antimicrobial in alignment medicine use in alignment with the with the national action plan National Health ii. Finalize and implement the national MoPH National Strategy 2024- antimicrobial stewardship and prescribing 2030 policy iii. Monitor the compliance of AMS MoPH National programs in facilities using the WHO CDC AMS toolkit iv. Mandate stewardship implementation MoPH National and as a part of the healthcare facilities Facility v. Create and audit the stewardship MoPH National and indicators to monitor the effectiveness of Facility the program in the facilities vi. Identify and develop new national MoPH National guidelines for prescribing based on existing gaps (include all Qatar relevant infectious diseases) to standardize and optimize prescriptions and rational use of antimicrobial drugs in human vii. Create good quality prescribing MoPH Facility indicators and encourage benchmarking at the facility level 64 Secondary Activities Lead Implementation Objectives Organization Level B. Establish i. Improve and continue training and MoPH National and Antimicrobial education for healthcare workers and Facility Stewardship public. education ii. Develop a curriculum for AMS and MoPH National program AMR awareness in undergraduate and postgraduate and residency and fellowship programs - adopting an interprofessional education (IPE) approach (doctors, pharmacists, nurses, dentists etc.) iii. Develop e-module which is compulsory MoPH National for licensing 5.3. Ensure adequate access and prudent use of antimicrobial agents in terrestrial and aquatic animals and agriculture. A. Develop i. Create multidisciplinary antimicrobial Animal Health National and and establish stewardship team with clear terms of Department Facility a multisectoral reference that facilitates antimicrobial (public/private) stewardship activities and reports to the antimicrobial national AMR Committee stewardship ii. Optimize implementation and Animal Health National and program monitoring of animal health regulation Department Facility iii. Establish policies and evidence based Animal Health National and standard therapeutic guidelines for Department Facility food production animals engaging all stakeholders in the process iv. Restrict the use of critically important Animal Health National and antibiotics for human medicines in food Department Facility production animals v. Develop and implement a system for Animal Health National and antimicrobial consumption surveillance and Department Facility collect data quarterly vi. Create a working group to develop a Animal Health National and system for registering and ensuring access Department Facility to high quality antimicrobials in animal health sector vii. Draft a policy document for off-label use of antimicrobials in food producing animals, and submit to the board 65 Secondary Activities Lead Implementation Objectives Organization Level 5.4. Enhance utilization of technology to support improvement in AMS practices and activities A. Introduce/ i. Mandate documentation of the MoPH/ Facility enhance appropriate clinical indication/diagnosis for Facilities electronic each antibiotic prescriptions/order health records (EHR) ii. Introduce/Improve advanced clinical Facilities Facility decision support system (CDSS) linking electronic prescribing with evidence- based medicine guidelines, diagnostic and laboratory results at facility level iii. Collaborate with National Electronic MoPH/ Facility Prescribing System. (E health national Facilities program) iv. Incorporate tools such as antimicrobial Facilities Facility stewardship module in the electronic system to guide appropriate prescribing of antimicrobials and help with conducting AMS activities and introduction of antimicrobial prescribing and stewardship application B. Introduce/ i. Promote microbiologic point of Facilities Facility enhance lab care testing to reduce unnecessary technology antimicrobial prescribing capability to ii. Promote the use of rapid microbiological Facilities Facility ensure timely and molecular testing to identify organisms treatment quickly and ensure patients are on best of serious antimicrobials infections 66 Secondary Activities Lead Implementation Objectives Organization Level 5.5 Ensure adequate funding and resources for AMS activities A. Leadership A. Ensure antimicrobial stewardship is a Facility Facility commitment, top priority for facility management and accountability, there is a facility AMS action plan with and allocated human and financial resources to responsibility initiate/continue AMS activities B. Identify a dedicated AMS leader/ Facility Facility champion who has dedicated staff time for AMS activities C. Form/maintain multidisciplinary Facility Facility AMS committee with clear terms of reference that monitors and measures the implementation of AMS activities D. Form/maintain AMS team with Facility Facility dedicated staff time including the AMS lead/champion, AMS pharmacist, microbiologist, IT pharmacist, data analyst, quality reviewer, and infection prevention practitioner E. Ensure monitoring and auditing of fund Facility Facility allocation to justify further activities 67

Appendix 6: Operational plan for AMR research Secondary Activities Lead Implementation Objectives Organization Level 6.1 Promote AMR research in alignment in partnership with national, regional, and international organization and institutions A. Establish a i. Conduct a situation analysis by: MoPH National Multisectoral a. Reviewing and assessing data generated National AMR by studies performed in the field of AMR Research in the state of Qatar and published in Technical international peer-reviewed journals during Working Group the period 2018-2022 (TGW) b. Evaluating the progress of ongoing studies and the potential relevance of the data these studies may generate for Qatar c. Analyzing existing policies and guidelines related to AMR to assess their degree of alignment with the local epidemiological data generated by relevant publications between 2018 and 2022 ii. Identify research gaps and develop a MoPH National priority National research agenda in AMR with specific research topics and questions to be addressed in the timeframe 2024- 2030 iii. Identify the most suitable research MoPH National groups to study priority AMR research topics, aiming to fill knowledge gaps and develop innovative approaches for AMR diagnosis, treatment, and prevention, with MoPH ensuring the allocation of necessary resources and funds iv. Ensure that the data produced by these MoPH National studies can be translated into practice by ensuring that national guidelines and policies are updated with the evidence generated 68

Appendix 7: Terms Of Reference 1. Awareness/Education Technical Working Group 1. Purpose To establish a nationwide well-coordinated Antimicrobial Resistance Program with well- defined and interconnected duties and functions of the program's many arms, with the goal of reducing AMR throughout the state of Qatar. To oversee the implementation of the objectives and activities of the National Action Plan that require sustained, coordinated, and complementary efforts of individuals and groups around the country, including healthcare providers, healthcare leaders, veterinarians, agriculture industry leaders, manufacturers, policymakers, and patients. The National IPC and AMR Section has established the AMR Program Technical Working Groups as a forum to support implementation of the AMR NAP 2024-2030. NAP AMR 2024-2030 educational priorities include: • Develop awareness educational program (train the trainer, campaigns, workshops) for healthcare professionals and for animal health, food safety and agriculture professionals. • Develop and implement multidisciplinary team training in the field of AM Prescribing and dispensing for example physicians, clinical pharmacist, and nurses. • Include antimicrobial stewardship principles and strategies in undergraduate and postgraduate curricula for medical, paramedical, and veterinary students and any relevant sectors. • Facilitate and ensure access to in-service training including continuous professional development (CPD) on antimicrobial prescribing and AMS for health-care professionals in the country. • Strengthen communication and education initiatives for animal health, food safety and agriculture professionals. • Integrate AMR awareness education program/campaign for public and cover different sectors (e.g., including AMR awareness program in school curriculum, all educational institutions), labor camps health centers, Food Industry, agri-business, and community). • Promote and Support World Antibiotic Awareness Week in all healthcare settings and public and animal health sector, agriculture, and food safety. • Endorse a “One Health” AMR Awareness approach. • Develop e-Learning modules for health professionals in human health and animal health. 69 • Develop local, regional, and international partnerships to improve and enhance all the interventions of the education, awareness and change of behavior activities in healthcare settings and animal, food, and agriculture settings. 2. Responsibilities The objective of the Educational TWG is to contribute to the development of the awareness and educational programs related to AMR nationally by: •Facilitating discussions to assess and review proposals •Addressing issues relating to the implementation of the NAP educational priorities and objectives • Provide oversight of implementation activities and readiness 3. Membership Members will be representative of a cross-section of stakeholder groups and will provide technical expertise. Members are expected to have a high level of personal and professional integrity, work together, and bring a broad perspective to issues and discussions raised. Members are also expected to champion the AMS program in their own unit and demonstrate leadership for AMS in their areas of practice as well as in their knowledge and attitudes. 4. Meetings Members will be required to meet regularly and contribute to the work of the TWG. The educational TWG will meet quarterly. Meetings may be held more or less frequently at the discretion of the Chair. Meeting agendas minutes will be provided and includes: • preparing agendas and supporting papers • preparing meeting notes and information 5. Quorum A quorum, consisting of half the number of members plus one, must be in attendance for decision-making. 6. Performance The AMR Education TWG shall provide an annual report to the National AMR and IPC Committee, including a review of the TWG Terms of Reference. 70 2. Antimicrobial Resistance Surveillance Technical Working Group 1. Purpose The purpose of the AMR Surveillance Technical Working Group (TWG) is to support the implementation of the National AMR Program by providing technical support for all National AMR Surveillance and National Antimicrobial Consumption Surveillance related activities in all "One Health" sectors. 2. Responsibilities The National AMR TWG is a National Multisectoral group covers both human and animal health sectors as well as the food and environmental sectors The AMR Technical Working Group Should: •Work as a central national governance/structure for “One Health” AMR surveillance at Ministry of Public Health (MoPH) • Support the National Coordination Center (NCC) for AMR Surveillance • Provide support for establishing and maintaining the national electronic surveillance system for AMR including identifying and prioritizing organisms and relevant antimicrobials that will be reported in each sector • Provide technical expertise for developing and enhancing a national monitoring and evaluations framework such as developing KPI to ensure that surveillance efforts are appropriately targeted • Develop central surveillance system to monitor and report antimicrobial consumption across all humans, animal health, food, and environment sectors • Support developing and reviewing AMR surveillance related policies • Support training program for laboratory staff for performing and interpretation of AST and AMR in all sectors 3. Membership The TWG will be led by a chair. Membership must include representatives from all "One Health" Sectors. These may include experts from areas such as infectious diseases, microbiology, infection prevention and control in human and animal health, pharmacy and drug control, public health surveillance system experts, environment, and others. 71 4. Meetings Members will be required to meet regularly and contributing to the work of the TWG. Meetings will happen twice per year or as determined by the chair. Members who do not show up to two meetings and/or fail to send an alternate, will be removed from the group. 5. Quorum A quorum, consisting of half the number of members plus one, must be in attendance for decision-making. 6. Performance Performance evaluation of the AMR Surveillance TWG will be conducted by the Chair of AMR Committee annually. The chair of the AMR Surveillance TWG shall provide an annual report to the National AMR Committee. 72 3. Infection Prevention and Control (IPC) Technical Working Group 1. Purpose To establish a nationwide well-coordinated Antimicrobial Resistance Program with well- defined and interconnected duties and functions of the program's many arms, with the goal of reducing AMR throughout the state of Qatar. To oversee the implementation of the objectives and activities of the National Action Plan that requires sustained, coordinated, and complementary efforts of individuals and groups around the country, including healthcare providers, healthcare leaders, veterinarians, agriculture industry leaders, manufacturers, policymakers, and patients. National IPC and AMR Unit has established the AMR Program Technical Working Groups as a forum to support implementation of the AMR NAP 2024-2030. NAP AMR 2024-2030 Infection Prevention and Control (IPC) priorities includes: • Develop policy on IPC practices to control the spread of Multidrug Resistant Organisms (MDROs), including managing patients in healthcare settings and community, in collaboration with different entities. • Create IPC guidelines for staff/workers/vets, farmers to prevent and control infection and potential contamination. • To develop IPC audit program/ process, including formulation of a national audit team in partner with subject matter experts. • Incorporate IPC program as part of the national biosecurity/ biosafety program. • Review facility licensing and accreditation standards to be aligned with IPC program. • Promote and Support World Antibiotic Awareness Week in all healthcare settings and public and animal health sector, agriculture, and food safety. Endorse a “One Health” AMR Awareness approach. • Develop IPC e-Learning modules for health professionals in human health and animal health. • Develop local, regional, and international partnerships to improve and enhance all the interventions of the IPC program and national biosecurity in healthcare settings, animal, food, and agriculture settings 73 2. Responsibilities The objective of the IPC TWG is to contribute to the development and implementation of IPC programs related to AMR nationally by: • Facilitating discussions to assess and review proposals • Addressing issues relating to the implementation of the NAP IPC priorities and objectives • Provide oversight of implementation activities and readiness 3. Membership Members will be representative of a cross-section of stakeholder groups, will provide technical expertise. Members are expected to have a high level of personal and professional integrity, work together and bring a broad perspective to issues and discussions raised. Members are also expected to champion the AMS program in their own unit and demonstrate leadership for AMS in their areas of practice as well as in their knowledge and attitudes. 4. Meetings Members will be required to meet regularly and contributing to the work of the TWG. The educational TWG will meet quarterly. Meetings may be held more or less frequently at the discretion of the Chair. Meeting agendas minutes will be provided and includes: • preparing agendas and supporting papers • preparing meeting notes and information 5. Quorum A quorum, consisting of half the number of members plus one, must be in attendance for decision-making. 6. Performance The AMR Education TWG shall provide an annual report to the National AMR and IPC Committee, including a review of the TWG Terms of Reference. 74 4. Antimicrobial Stewardship Technical Working Group 1. Purpose The National AMR TWG is a National Multisectoral group covers both human and animal health sectors as well as the food and environmental sectors. The purpose of the AMS -TWG is to provide support and guidance to promote the successful implementation and maintenance of a comprehensive AMS service across QATAR health care system. The aims of this group are to promote the efficient, safe, and appropriate use of antimicrobials thereby optimizing clinical outcomes while minimizing unintended consequences of antimicrobial use including toxicity; under or overdosing; inappropriate antimicrobial selection and emergence of resistant organisms. 2. Accountable to: • The national safety and quality health service at ministry of public health • National AMR committee 3. Function and Responsibilities The AMR Technical Working Group Should: • Work as a central national governance/structure for “One Health” AMR surveillance at MOPH • Support the National Coordination Centre (NCC) for antimicrobial stewardship program implementation within health care facilities • To review health care facilities AMS program progress and make recommendations in the implementation of WHO’s priority activities to tackle AMR • Provide support for maintaining the national electronic surveillance system for AMR including identifying and prioritizing organisms and relevant antimicrobials that will be reported in each sector • Provide technical expertise for developing and enhancing a national monitoring and evaluations framework such as developing KPI to ensure that surveillance efforts are appropriately targeted • Monitor and report antimicrobial consumption across all humans, animal health, food, and environment sectors • Support developing and reviewing antimicrobial prescription related policies • Provide an independent evaluation of the major scientific and technical challenges and opportunities in order to enhance progress in addressing AMR in the context of human health • Review and make recommendations regarding the adequacy of health care facilities response to emerging national health risks with regards to AMR 75 4. Membership and Chair Membership must include representatives from all "One Health" Sectors. These may include experts from areas such as infectious diseases, microbiology, infection prevention and control in human and animal health, pharmacy and drug control, public health surveillance system experts, environment, and others. 5. Frequency of meetings: The meetings should be held on a regular basis, ideally quarterly. Meetings may be held more or less frequently at the discretion of the Chair. Members shall delegate a proxy to attend meeting of AMS -TWG in their absence. Guests are invited by the Chair to attend meetings of the AMS -TWG. Meeting agendas minutes will be provided and includes: • Preparing agendas and supporting papers • Preparing meeting notes and information The agenda will be distributed to the members and attendees 1 week prior to the meeting. The proceedings of all meetings will be recorded to reflect the work done by the AMS -TWG and these minutes will be endorsed by this committee at the following meeting. 6. Quorum: A quorum, consisting of half the number of members plus one, must be in attendance for decision-making. 7. Performance: The AMS -TWG shall provide an annual report to the national Safety and Quality Health Service at ministry of public health and the national AMR committee. 76 5. Research Technical Working Group 1. Purpose • Provide strategic leadership on National AMR Research agenda under the National Action Plan on AMR. • Provide a coordinated approach for national, healthcare, and non-healthcare organizations and community AMR Research programs (set priorities, financial allocations, etc.). • Support national, regional, and international efforts as appropriate. The overall aim of the National AMR Research Technical Working Group (TWG) is to set and implement a national research agenda into AMR in affected sectors (humans, animals, agriculture & environment) applying “One Health” approach. The TWG is accountable to: • National AMR multisectoral Committee • Research organizations and others as applicable 2. Responsibilities • Develop & monitor national research agenda for the affected sectors in alignment with National Action Plan on AMR • Review and prioritize research topics that align with the goals of the national AMR program and address the unique challenges of Qatar • Coordinate mobilization of resources (fund & manpower) for the implementation of the research agenda into AMR within the sectors • Support national work on strengthening national capacity in research to tackle AMR, in line with the National Antimicrobial Resistance Plan (NAP) • Facilitate collaboration between researchers, institutions, and stakeholders both within Qatar and internationally • Where possible, provide technical guidance on research methodologies, study designs, and data collection strategies to ensure high-quality research • Where possible, monitor ongoing research projects, review interim findings, and ensure that the research remains on track and aligned with the program objectives • Ensure effective dissemination of research findings to all stakeholders, policy makers, healthcare practitioners, and the public to influence evidence-based decision making • Develop & monitor a national repository platform to where data sets, presentations, and publications are stored and accessible for all research groups to enhance collaborative endeavors 77 3. Membership The national AMR RTWG will comprise multidisciplinary experts from various fields including, but not limited to: • Members representing the relevant departments within the Ministry of Public Health (MOPH) responsible for the selection, supply, distribution, prescribing and use of antimicrobials at the national level. • Members representing academia, infectious diseases, microbiology, epidemiology, clinical medicine, public health, pharmaceutical sciences, health economics, social sciences. • Members representing animal health (veterinary medicine), food, and environment sectors. • Representatives should be given sufficient authority by their institutions to make decisions. The RTWG members should always remain engaged, striking a balance between full representation and the functionality of the group to coordinate a national RTWG. 4. Meetings The meeting format and rules should conform to national norms. A chairperson should be selected based on his or her expertise in leadership. Rotation of the chair among members of the TWG could be considered. The RTWG should convene regularly, at least quarterly, or biannually, to discuss progress and address emerging challenges. Meeting minutes and recommendations will be documented and shared with relevant stakeholders. 5. Quorum A quorum, consisting of half the number of members plus one, must be in attendance for decision-making. 6. Performance Performance the Research -TWG shall provide an annual report to the national Safety and Quality Health Service at ministry of public health and the national AMR committee. 78 References • Balkhy, H., Assiri, A., Mousa, H., Al-Abri, S., Al-Katheeri, H., Alansari, H., Abdulrazzaq, N., Awa Aidara-Kane, Didier Pittet, Didier Pittet, Awa Aidara-Kane, Elisabeth Erlacher-Vindel, Hail Mater Al Abdely, Adel Al Othman, Sameera M. Al Johani, Abubaker Fadlelmula, Aiman El- Saed, Gregory Poff, Abdulrahman Al Habrawy, Yousuf Al Omi, Alaa Saeed Mutlaq, Ahmed Hakawi, Mohammed Al Zahrani, Sami Al Hajjar, Sahar Al Thawadi, Ali M. Somily, Hosam Al Zowawi, Saeed Al Shahrani, Mohamed Al Quwaizini, Ali Al Sahaaf, Mohammed Fayez Ahmed Salim, Kamal Hossein Zidan, Safaa Abdulaziz El Khawajah, Jameela AlSalman, Nermin Kamal Hasan Mohamed Saeed, Noura Al Qalloushi, Abeer Aly Omar, Najiba Abdulrazzaq, Zaina Maskari, Faryal Ali Khamis Al Lawati, Hilal Al Hashami, Mubarak Al Yaqoubi, Khalifa Al Shaqsi, Huda Al Harthi, Khalid Hamid Youif Elawad, Wael Ezzeldin Said Hussein, Yasser Mohamed Abdelkader Morsy, Salah Ahmed Abdalkarim Taha, Eman Abdulrahman Al Maslamani, Maryam Al Sulaiti, - The strategic plan for combating antimicrobial resistance in Gulf Cooperation Council States, Journal of Infection and Public Health, Volume 9, Issue 4, 2016, Pages 375-385, ISSN 1876-0341, https://doi.org/10.1016/j.jiph.2016.03.003. 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