Zimbabwe One Health Antimicrobial Resistance National Action Plan 2017-2021

1.0 BACKGROUND AND SITUATION ON AMR .................................................................... 1

2.0 EXECUTIVE SUMMARY . ................................................................................................ 4

3.0 GOVERNANCE . ............................................................................................................. 6

3.1 Governance structure ................................................................................................ 6

3.2 Leadership ............................................................................................................... 6

3.2.1 Roles of the appointed positions ........................................................................ 7

3.3 Guiding principles ����������������������������������������������������������������������������������������������������� 9

4.0 STRATEGIC FRAMEWORK . .......................................................................................... 10

4.1 STRATEGIC PLAN AND STRATEGIC OBJECTIVES FOR AMR IN ZIMBABWE . ......... 11

4.1.1 Strategic objective 1 – Education, training and awareness: To raise awareness and educate the population, professionals and policy makers on AMR....................... 11

4.1.2 Strategic objective 2 – Surveillance: Improve detection and understanding of the AMR and antimicrobial use patterns and trends through surveillance. ...................... 11

4.1.3 Strategic objective 3 – Infection prevention & control, good animal husbandry and biosecurity: Reduce the need for antimicrobials by improving IPC, animal health and management practices including biosecurity, WASH and immunisation. ............. 13

4.1.4 Strategic Objective 4 – Rational use of antimicrobials: Improve controlled access and optimise the use of antimicrobials in humans and animals..................................14

4.1.5 Strategic objective 5 – Sustainable Investment into AMR interventions and re- search into new antimicrobials and alternatives to antimicrobials. .............................. 15

5.0 OPERATIONAL PLANS. .................................................................................................16 5.1 Strategic objective 1 – Education, training and awareness..........................................16

5.2 Strategic objective 2 – Surveillance.......................................................................... 23

5.3 Strategic objective 3 – Infection prevention and control and biosecurity. .................... 29

5.4 Strategic Objective 4 – Rational use of antimicrobials................................................ 34

5.5 Strategic objective 5 – Investment into research and development.............................39

6.0 MONITORING AND EVALUATION. ............................................................................... 42

6.1 Approach and components of M&E........................................................................... 42 ABBREVIATIONS AND ACRONYMS AMR Antimicrobial resistance ICAZ Infection Control Association of Zimbabwe AMU Antimicrobial use IDSR Integrated Disease Surveillance CDC Centers for Disease Control and and Response Prevention IPC Infection Prevention and Control CDDEP Center for Disease Dynamics, IEC Information, Education and Economics & Policy Communication CEO Chief Executive Officer LMAC Livestock & Meat Advisory CIA Critically Important Council Antimicrobials MAMID Ministry of Agriculture, CPD Continuous Professional Mechanization and Irrigation Development Development CSO Civil Society MCAZ Medicine Control Authority Zimbabwe CVL Central Veterinary Laboratory MDRO Multi-drug resistant organism DDD Defined Daily Doses MEWC Ministry of Environment, Water and Climate DLS Directorate Laboratory Services MLCSCZ Medical Laboratory and Clinical DLVS Department of Livestock and Scientists Council Zimbabwe Veterinary Services MoHCC Ministry of Health and Child Care DPS Department of Pharmacy Services MoE Ministry of Education DR&SS Department of Research and MoF Ministry of Finance Specialist Services DVS Division of Veterinary Services MoS&T Ministry of Science & Technology EMA Environmental Management NAP National Action Plan Agency EML Essential Medicines List NBA National Biotechnology Authority FAO Food Agricultural Organisation of NGO Non-governmental organisation the United Nations NHIS National Health Information GAL Government Analyst Laboratory System GARP Global Antibiotic Resistance NIPCC National Infection and Partnership Prevention Control Committee HAI Health-care associated NMRL Naitonal Microbiology Reference infections Laboratory HCW Health-care workers NMTPAC National Medicine & Therapeutics Policy Advisory HMTC Hospital medicines therapeutic Committee committees THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 v OIE World Organization for Animal Health PATAM Health-care workers RCZ Hospital medicines therapeutic committees ReAct Infection Control Association of Zimbabwe STG Standard Treatment Guideline STI Sexually Transmitted Infections TMPC Traditional Medical Practitioners Council TMD Traditional Medicines Department TWG Technical Working Group UZ University of Zimbabwe VHW Village Health Workers VMDG Veterinary Medicines General Dealers WASH Water Sanitation and Hygiene WHO World Health Organization ZACH Zimbabwe Association of Church-related Hospitals ZiMA Zimbabwe Medical Association ZIMCHE Zimbabwe Council for Higher Education ZIMRA Zimbabwe Revenue Authority ZINATHA Zimbabwe National Traditional Healers Association ZINQAP Zimbabwe National Quality Assurance Programme ZINWA Zimbabwe National Water AUthority ZRP Zimbabwe Republic Police ZVA Zimbabwe Veterinary Association THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 vi Foreward Antimicrobial resistance (AMR) has become an increasingly serious threat to national and global public health that requires prioritised action across all government sectors and society. Antimicrobials have been hailed as one of the most important discoveries in medical history as they have successfully treated many diseases in both animals and humans promoting the health and well-being of individu- als. AMR is threatening the effective prevention and treatment of an ever increasing range of infec- tions caused by bacteria, viruses, parasites and fungi and impacting on the health and productivity of livestock. It is important that we preserve the current antimicrobials that are available as it takes an average of 12 years for new antimicrobials to be available for use. Following the adoption of the Global Action Plan (GAP) on Antimicrobial Resistance by the 68th World Health Assembly in May 2015, Zimbabwe immediately put in place a framework towards developing the AMR National Action Plan by starting with a situational analysis to help understand the situation around AMR and any efforts to contain it that were in place. The Global Action Plan urges Member States “to have in place, national action plans on antimicrobial resistance and with standards and guidelines established by relevant intergovernmental bodies.” Findings of the AMR situation analysis that was carried out showed that AMR will grow in Zimbabwe if it is not tackled in a holistic manner. This national action plan is in line with the Global Action Plan and outlines the following 5 strategic objectives:- • To improve awareness and understanding of AMR through effective communication, education and training; • To strengthen the knowledge and evidence base through surveillance and research; • To reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures; • To optimize the use of antimicrobial medicines in human and animal health; • To develop the economic case for sustainable investment that takes into account the needs of all countries and to increase investment in new medicines, diagnostic tools, vaccines and other inter- ventions. Therefore, the three governmental departments and other relevant stakeholders whose responsibili- ties intersect on human, animal and environmental health outcomes, and therefore are responsible for implementing the ‘One Health’ approach in Zimbabwe, have committed themselves to investing resources in designing sound strategies and interventions to preserve the effectiveness of our antimi- crobial agents, in order to ensure sustainable dependence on them and to slow down the emergence and spread of AMR in Zimbabwe. This National Action Plan on AMR will be implemented by all sectors in coordinated manner to significantly slow down the development of antimicrobial resistance. Dr. Pagwesese David Parirenyatwa Dr. Joseph Made Ms. Oppah Muchinguri-Kashiri Minister of Health Minister of Agriculture Minister of Environment and Child Care Mechanization and Irrigation Water and Climate Development THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 vii Acknowledgements The Ministry of Health and Child Care, the Ministry of Agriculture Mechanisation and Irrigation De- velopment and the Ministry of Environment, Water and Climate would like to thank the World Health Organization (WHO), Food and Agriculture Organization (FAO) of the United Nations for the financial and technical support during the development of this document. Special thanks also go to the Global Antibiotic Resistance Partnership (GARP), under the Centers for Disease Dynamics, Economics & Policy (CDDEP) and Action on Antibiotics Resistance (ReAct) for their support and guidance of both the Situation Analysis and the National Action Plan (NAP). The three ministries are grateful for the commitment and involvement of the Zimbabwe Antimicrobial Resistance Core Group and the 5 technical working groups who have been working tirelessly in the production of these documents usinga ‘One Health’ approach. Special thanks also go to the core national action plan writing team who were:- Sekesai Mtapuri-Zinyowera, Ministry of Health & Child Care Tapiwanashe Kujinga, Pan-African Treatment Access Movement Portia Manangazira, Ministry of Health and Child Care Unesu Ushewokunze-Obatolu, Ministry of Agriculture, Mechanisation and Irrigation Development Ropafadzai Hove, Ministry of Health and Child Care Pamela Woods, University of Zimbabwe, Department of Animal Science Newman Madzikwa, Ministry of Health and Child Care Valerie Robertson, University of Zimbabwe, Department of Medical Microbiology Jairus Machakwa, Division of Veterinary Services Zivanai Makoni, Medicines Control Authority of Zimbabwe Stanley Midzi, World Health Organisation Lawrence Dinginya, Division of Veterinary Services Marcelyn Magwenzi, University of Zimbabwe, Department of Medical Microbiology Kudzaishe Vhoko, Division of Veterinary Services Tsitsi Monera-Penduka, University of Zimbabwe, School of Pharmacy Samuel Swiswa, Division of Veterinary Services Wilfred Motsi, Ministry of Water, Environment and Climate Jose Alves Phiri, Ministry of Health & Child Care Jonathan Mufandaedza, National Biotechnology Authority of Zimbabwe Elizabeth Gonese, Centers for Disease Control and Prevention Francisca Mutapi, University of Edinburgh, Institute for Infection and Immunology Research Takafira Mduluza, University of Zimbabwe, Biochemistry Department THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 viii 1. BACKGROUND AND SITUATION ON AMR The Government of Zimbabwe through the antimi- diarrheal diseases. One major driver of resistance is crobial resistance (AMR) core group conducted an increased antimicrobial consumption in both humans analysis of the AMR situation in Zimbabwe in the and animals. However the data on antimicrobial use human, animal and environmental sectors follow- and patterns of AMR in humans and animals in Zim- ing the ‘One Health’ approach advocated by World babwe are limited. Health Organization (WHO), World Organisation for Animal Health (OIE), and Food and Agriculture Although the country’s vaccination coverage rate for Organization of the United Nations (FAO). This in- children under 1 year is at 89%, more can be done terest is borne out of the fact that AMR is a cross to prevent infections, including improving general cutting problem affecting human, animal and the hygiene and sanitation and implementing infection environment that calls for coordinated action across prevention and control (IPC) measures in all health these sectors. It develops from changes at genetic institutions. A significant dent has been made in the levels through mutations or as acquired traits in the occurrence of rotavirus diarrhoea through vaccina- microorganism. As a naturally occurring phenom- tion; however the persistent challenges of poor water, enon, AMR is accelerated by selection pressure in sanitation and hygiene practices have kept diarrhoea the environment of the microorganism. Because cases related to typhoid and other bacteria causes as microorganisms are present in the natural environ- common occurrences. Whilst oral rehydration with ment, when AMR develops, it can also escalate and Zinc, is the standard treatment of choice for diarrhoea, spread in the environment with implications on the antibiotics are often used and resistance is spreading. well-being of all forms of life. Events precipitating In Zimbabwe there is lack of meaningful surveil- AMR in microorganisms can therefore have impli- lance data to help understand resistance patterns, cations on pathogenicity and therefore plant, ani- prevalent organisms and guide policy development, mal and human health. This puts pressure on the due to constraints in the laboratory testing systems. ability of human and animal health systems as well Only 25 percent of the human public health labora- as agricultural production, particularly as the pace tories have the necessary staffing, equipment and of discovery and innovation of more effective anti- reagents to perform culture and susceptibility testing microbials has significantly slowed down over the on human samples, which limits the diagnostic ca- last three decades. pabilities of health care professionals treating patients Zimbabwe has faced serious economic challenges and the availability of antimicrobial resistance data to over the years, which have affected all aspects of guide clinical practice and policymaking. life, not least of which is the health sector’s ability Zimbabwe has an essential medicines list (EML) to provide health care, and which has resulted in a that was last updated in 2015, but access to antimi- shortage of health-care workers and stock outs of crobials is still limited in many areas, and should be medicines. The agriculture sector is one of the most expanded alongside efforts to improve supply chains important pillars of the Zimbabwean economy, with and storage. The primary reason for lack of access the majority of the population dependent directly or to medicines is lack of finances at the national level indirectly on agriculture. and fragmented funding from donors. Widespread Zimbabwe faces significant and growing resistance unregulated availability of antimicrobials over-the- in common infections such as TB, malaria, HIV, re- counter (OTC) for use in humans and animals has spiratory infections, sexually transmitted infections been reported despite regulations that prohibit sale (STIs), urinary tract infections (UTIs), meningitis and without a valid prescription and the possibility that THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 9 a pharmacist may lose their license or be fined for cern about dangers of residues of veterinary medical contravening these laws. More needs to be done agents in food for consumers. For a wide variety of to improve incentives for appropriate antibiotic use, infections especially those caused by viruses, and create disincentives for the overuse of antibiotics some bacteria, effective vaccines are available for and illegal access to antimicrobials of poor quality prevention. Some vaccination programs are offered through sound legislation and policy. as a public good depending on their importance to production system economies and to public health. The use of antimicrobials in crop production is For others, the adoption of good animal husbandry less well acknowledged although there is potential and hygienic practices may go a long way in reduc- in the food horticulture industry. ing infection pressure. While these alternatives to antimicrobial use (AMU) are being promoted, some Infectious diseases caused by microbiological important diseases such as vector-borne rickettsial agents including bacteria, fungi, protozoa and vi- (Erlichia of ruminants and dogs) and protozoan (Ba- ruses in animals inflict significantly important eco- besiases, Trypanosomiasis, Theileria spp) diseases nomic and public health impact in animal produc- could benefit from development of effective, user- tion systems. The use of antimicrobial agents is friendly vaccines. Vector-borne diseases therefore therefore an important aspect of animal healthcare. still rely on chemical vector control with its environ- However, because of the constant infection chal- mental implications or the frequent use of antibiot- lenge to animals in the environment, overdepen- ics for some of them. The range of options in the dence and abuse of antimicrobials have contribut- prevention of microbial infections can therefore still ed to the development of AMR, which results from be explored through research. selection pressure at genetic level. This tendency is being exacerbated by the need for repetitive treat- Animal disease surveillance is one of the im- ment such as occurs in milk producing animals portant tools for intelligence gathering to facilitate and mass treatments as called for in managing early detection of higher impact endemic and small stock and aquatic animal infections. In other trans-boundary animal and zoonotic diseases and instances, the prophylactic and metaphylactic use pests. General and disease specific surveillance is of antimicrobial medicines, in order to achieve sus- also a useful tool in the generation of evidence for tainably high productivity levels, are to blame for sanitary safety assurance of traded animal-source the rising occurrence of AMR, which risks affecting products. Disease specific surveillance programs the availability of some key antibiotics essential for exist for brucellosis in dairy cattle, salmonellosis in use in treatment of human disease. breeder poultry flocks and slaughtered cattle and pigs aimed at infection reduction. Surveillance data The regulatory oversight on the use of veterinary could be of additional use in the determination of medicines suffers from the weak distribution of emerging risks due to AMU and resistance. This re- veterinary services particularly in the numbers and quires laboratory testing capacity and capability for distribution of veterinarians and veterinary parapro- the determination of resistance as well as monitor- fessionals. This defeats the intention of the medi- ing for residues in animal tissues. cines control legislation whose aim is to promote the rational and safe use of medicines. A large Present veterinary laboratory testing capacity is lim- range of prescription medicines can therefore be ited by personnel skills and equipment. Culture and accessed and used by lay personnel and animal sensitivity tests for AMR and a limited range of residue keepers without the necessary controls to ensure testing can be done, especially in support of animal- judicious and prudent use. source food exports but no monitoring is carried out for the local market on a ‘client pays’ basis. There are Greater reliance on preventive veterinary medicine currently limited capacities to support a comprehen- has however been gaining popularity due to the con- sive residue monitoring programme in animal slaugh- THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 10 ter establishments, and to monitor or regulate residue more research to be done including surveillance. In levels in abattoir waste and their disposal pathways. order to prevent resistance, cultural methods are em- The confirmatory tests for AMR still take long and ployed to control diseases such as crop rotation, use could benefit from the development and adaptation of of clean seed and use of resistant varieties. more rapid detection methods to facilitate rapid and Environmental monitoring and surveillance for precise decisions on the choice of medicines remov- AMR needs to be mainstreamed within a general na- ing the element of “trial and error”. tional strategy to scale down the rate of emergence Widespread unregulated availability of over the of AMR. To do this, a clear understanding is required counter medicines and informal cross-border impor- of drivers in each sub-sector in relation to safeguards tation of antimicrobials for use in humans and animals on the lists of essential veterinary and medical anti- has been reported despite legislation prohibiting sale microbials, especially those intended for specific use without prescription. Policy, legislation and implemen- in human disease. tation gaps have allowed the routine inclusion of an- Access to good water and sanitation facilities tibiotics in feeds, while weak veterinary capacity has is lowest in rural areas, where two thirds of the been blamed for the wide access to antimicrobials by population resides including a few residential animal keepers, without the necessary checks. En- areas in the urban areas. Added to this, hospitals, forcement of existing legal provisions and incentives clinics and manufacturing industries have poor for appropriate antibiotic use, with disincentives for liquid and solid waste disposal methods and the the overuse of antibiotics and illegal access to antimi- capacity to regulate the disposal and treatment of crobials are required. clinical waste is limited. As a result, antimicrobials Chemicals are used in the crop sector as fungicides and antimicrobial residues are likely entering the or for their bacteriostatic effects. There is need for environment, including drinking water and soil. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 11

2.0 EXECUTIVE SUMMARY The AMR situation analysis that was carried out by the The NAP will also prioritise the building of labora- multi-sectorial Zimbabwe AMR Core Group indicated tory diagnostic capacity, as this forms the basis for that the problem of AMR, caused by a combination treatment decisions for human and animal health- of factors, can be addressed through a roadmap to- care professionals and supports informed decisions wards slowing down the pace of AMR development about AMU. Laboratory capacity is also needed to and enhancing sustainable reliance on AMU in public conduct AMR surveillance, which will be incorpo- health promotion. The following 5 strategic objectives rated into the existing integrated disease surveil- were identified in Zimbabwe, which align with the lance and response (IDSR) system for humans and WHO Global Action Plan objectives, in order to ensure notifiable disease surveillance system for animals. preservation of the available antimicrobials so that in- A combined surveillance reporting system will be fectious diseases are treatable: created to ensure the One Health approach to un- derstanding the magnitude, patterns and dynamics • Raise awareness and educate the population, of AMR. A monitoring system for AMU will be estab- professionals and policy makers on AMR. lished in the public and private sectors to measure and monitor the usage of antimicrobials in humans, • Improve understanding of the AMR burden animals and crop production, its disposal into the and antimicrobial use patterns through sur- environmental, and determine the impact of AMR veillance. interventions on reducing use. • Reduce the need for antimicrobials by improv- In order to minimize the development of AMR, ing infection prevention and control, improved renewed attention will be brought to current infec- farm practices and biosecurity, water sanita- tion prevention and control practices to reduce the tion and hygiene, and immunisation. spread and transmission of multi-drug resistant or- • Improve controlled access and optimise the ganisms (MDROs). Surveillance of hospital-acquired use of antimicrobials in humans and animals infections (HAIs) will support these efforts. Biosecu- rity measures, and better hygiene and health man- • Sustainable investment into AMR and re- agement practices for animals will be promoted and search into alternatives to antimicrobials. strengthened through improved policies, guidelines and practices, training and capacitation of regulatory This National Action Plan (NAP) will help to plan the bodies to improve enforcement and testing mecha- development and implementation of a comprehen- nisms. The relevant authorities will focus on appro- sive national communication and awareness plan to priate environmental controls, the provision of water, educate the public, professionals and policy makers on sanitation and hygiene (WASH) facilities in commu- ways to prevent infections, treat infections appropriately nities, health and veterinary facilities, and promotion and conserve antimicrobials. It will strengthen the edu- of improved hygiene behaviours. cation curriculum in all educational sectors from pri- mary to tertiary education, improving the knowledge of Stewardship programs will need to be incorpo- school children and educating human, animal and en- rated into the hospital medicines therapeutic com- vironmental health care professionals, both as students mittees (HMTCs) to ensure prudent and appropri- and postgraduates, to be aware of the threat of AMR ate use of antimicrobials. Measures will need to be and ways to minimize its development and spread in implemented to ensure consistent and sustained humans, animals and the environment. access to quality medicines by strengthening pro- THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 12 curement systems, supply chains and storage fa- updated EML that reflects the current diseases and cilities for antimicrobials and ensuring sustained pathogens in humans to improve treatment. funding for the antimicrobials on the Essential Med- icines List (EML). Control of quality veterinary medi- Both short-term and long-term research needs cines will need to be increased and simultaneously to be carried out to understand the links, drivers strengthened without limiting access to animal keep- and dynamics of AMR development and spread be- ers through enhanced involvement of veterinarians tween the human, animal, and environmental inter- in the provision of guidance on antimicrobial use faces and to create innovative diagnostic tools, new in the field as well as scope of practice for veteri- vaccines, and alternative therapies such as probi- nary paraprofessionals under veterinary oversight. otics and traditional remedies. Funding for these Public access to antimicrobials at the point of the types of research activities will be provided by the pharmacy and veterinary medicine general dealers Government with the support and collaboration of (VMGDs) is to be controlled through improvements development partners and the private sector. to regulatory processes. This will ensure prudent Implementation of this plan requires sustained use without undermining access to quality antimi- commitment into years to come and a monitoring crobials and care. and evaluation plan will be needed to evaluate its At the same time, the rational use of antimicro- impact. The plan will be achieved through the “One bials in health facilities will be improved through Health” approach which embraces an integrated, functional hospital medicines therapeutic commit- unified effort across sectors, addressing the cross tees, standard treatment guidelines (STG’s) and an cutting nature of AMR. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 13

3.0 GOVERNANCE

3.1 Governance Structure The AMR governance structure was formed and en- The governance structure was formed after a dorsed in August 2016 by the Secretary for Health consultative process that involved relevant stake- and Child Care to allow for coordination, manage- holders from the relevant ministries, civil society ment and monitoring of AMR activities in the coun- (CSOs), academia and non-governmental orga- try (See Figure 1 below). The AMR focal point is the nizations (NGOs). Technical working groups that AMR Coordinator who will work under the Depart- are aligned to the strategic objectives of the Global ment of Epidemiology and Disease Control (EDC), Action Plan were formed at a multi-sectoral ‘One the Directorate Laboratory Services (DLS) in the Health’ stakeholder’s forum that was held in June Ministry of Health and Child Care (MoHCC) and the 2016 (See Figure 1 below). Division of Livestock and Veterinary Services (DLVS). Fig 1: Governance structure of the Zimbabwe AMR activities

3.2 Leadership The Secretary for Health in the MoHCC is the office Irrigation Development and the Ministry of Environ- that is responsible for leading national AMR activi- ment, Climate & Water. The focal point, the Zimba- ties. The Core Group shall also report to the Perma- bwe AMR Core Group and the Advisory Committee nent Secretaries through the advisory committees were all appointed by the Secretary for Health for a in the Ministry of Agriculture, Mechanisation and period of 5 years. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 14

3.2.1 Roles of the appointed positions • The national delegation to the World Organ- isation of Animal Health (OIE) AMR Focal Point • University of Zimbabwe The functions of the National AMR focal point include: • Biomedical Research and Training Institute i. Building sustained partnerships and working nationally and internationally on containment • Civil society of AMR; • National Biotechnology Authority of Zimba- ii. Leading and coordinating activities of the bwe AMR National Action Plan; • Ministry of Finance and Economic Develop- iii. Facilitating and overseeing implementation of ment activities through the AMR Core Group; The roles and responsibilities of the AMR Core iv. Ensuring regular data collection and informa- Group include: tion sharing by instituting effective communi- cation and coordination mechanisms among i. Mobilising resources for the national response all stakeholders, the members of the Core against AMR. Creating correct and relevant Group and their constituencies, sectors and messaging on AMR in order to guide education disciplines and; and awareness programmes on AMR to ensure that the public and all other relevant stakehold- v. Coordinating national activities as per the Na- ers are sensitised on AMR issues. tional Action Plan for the AMR program. ii. Facilitating the establishment of surveillance The Zimbabwe AMR Core Group systems to monitor AMR. The Zimbabwe AMR Core Group is a multi-sectoral iii. Disseminating active and passive surveil- group comprising of 18 members, an appointed lance data on antimicrobial use (AMU) and in- Chairperson, Deputy, Coordinator, Secretariat and tegrated laboratory surveillance data to policy Committee Members. Members of the Core Group makers and other relevant partners. are from the following organizations: iv. Enabling research activities on relevant AMR • Ministry of Health & Child Care issues. • Ministry of Agriculture, Mechanisation and v. Encouraging rational use of medicines through Irrigation Development the establishment of antimicrobial steward- ship programs. • Ministry of Environment, Climate & Water vi. Supporting the implementation of infection pre- • Department of Livestock and Veterinary vention and control (IPC) and biosecurity mea- Services sures to reduce and control the spread of AMR. • Medicines Control Authority of Zimbabwe vii. Monitoring implementation of AMR-related • Food & Agricultural Organization of the activities by other organisations, institutions United Nations (FAO) and stakeholders. • World Health Organization (WHO) viii. The AMR Core Group will be accountable for the process of implementation of this NAP. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 15 The Zimbabwe AMR Advisory Committee vi. Identifying any gaps in the evidence base, such as those requiring further research or There is a multisectoral 12-member Advisory Com- surveillance. mittee made up of policy makers within the three core ministries, consultants from the University of Five technical working groups (TWG) that are Zimbabwe, FAO, WHO, CDC and interested private aligned with the strategic objectives of the Global practitioners from both human and animal health. Action Plan were formed in June 2016, as follows: This committee has strategic governing responsi- • Education and Awareness bilities that include the following: • Surveillance and Research i. Providing practical advice and guidance to the process of carrying out an AMR situational • Infection Prevention & Control and Biosecurity analysis and the national action plan. • Antimicrobial Use ii. Providing advice and guidance in the imple- mentation, monitoring and evaluation of the • Research and Development AMR NAP. The chairperson of each TWG is a member of the iii. Contributing to improved capacity, includ- Zimbabwe AMR core group. The roles and respon- ing research advice, practical and scientific sibilities of TWGs include the following: advice to the Core Group and government on • Building sustained partnerships and work in strategies to: their sector on containment of AMR; - minimize the incidence of healthcare as- • Identifying other relevant stakeholders; sociated infections (HAIs) • Facilitating and overseeing implementation, - monitor AMR and reduce its develop- including monitoring and evaluation (M&E) of ment and spread the NAP through the TWG; - maintain the effectiveness of antimicro- • Ensuring regular data submission and informa- bial use (AMU) and optimize antimicrobial tion sharing to the Core Group by instituting prescribing in the treatment and preven- effective communication systems, frameworks tion of microbial infections and coordination among all members of the - take into account the relevant work of TWG. other expert groups, in the human and vet- erinary fields when making its recommen- dations

3.3 Guiding Principles iv. Assisting the Zimbabwe National AMR Core group on its scientific priorities and work, The guiding principles that the Zimbabwe NAP will fol- including horizon-scanning and long-range low are in line with those articulated in the 68th WHA: planning as well as dealing with immediate (i) Whole-of-society engagement including a One risks and opportunities. Health Approach v. Reviewing and evaluate the effectiveness of A knowledge, attitudes and practices survey of the the on-going work of the AMR core group. general public and animal and human health pro- THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 16 fessionals and a point-prevalence survey carried microbials prescribed by qualified professionals out in 18 hospitals showed widespread irrational and used appropriately by individuals will ensure antimicrobial use and varied knowledge of AMR. quality health care provision at low cost. The whole of society should therefore be engaged in curbing AMR in the country as each individual (iv) Sustainability has a role to play, hence education and awareness Implementation of this NAP will require to be of AMR will be intensified. integrated into the work programs of all relevant (ii) Prevention first ministries to ensure activities will be carried out. Therefore, political commitment and international Water, sanitation and hygiene (WASH), improved collaboration and support are needed to promote practices in individuals, among medical and veteri- the technical and financial investment necessary nary professionals, organisations and at the farm lev- for effective running of the NAP interventions. els are low cost interventions areas with immediate Government institutions and other relevant sec- impact to prevent the spread of infections. These are tors will need to commence utilising the available basic first steps that can be undertaken, followed by resources and build on this to ensure sustainabil- infection prevention control in hospitals, better bios- ity. ecurity and good farm practices and routine vaccina- tion of humans and animals. (v) Incremental targets for implementation (iii) Access This NAP has a phased approach that can be achieved in a stepwise manner, considering Access to information on AMR is key to empower- short-term priority areas in the five strategic ob- ing individuals and the nation as a whole. Access jectives in order to meet both local needs and to diagnostic services and access to quality anti- global priorities. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 17

4.0 STRATEGIC FRAMEWORK The Zimbabwe NAP is built on a foundation of re- to optimise responsible use in animals and search and development and the necessary politi- humans cal commitment and investment to ensure the sus- • Investment in research and development which tainability of the AMR program. seeks innovative ideas of alternatives to antimi- The four key pillars of the strategy are: crobials or quicker diagnostic techniques. • Surveillance of AMR and AMU patterns in ani- Finally, the implementation of the Zimbabwe NAP mals, humans and crops. depicts a strong inter-sectoral coordinating mecha- nism as its foundation and has its roof which is • Prevention, which will reduce the need for antimi- overarching and cross-cutting indicating the need crobials through effective IPC, farm biosecurity and to raise awareness and educate the public, profes- good farm practices, WASH and immunisation sionals and policy makers on AMR and responsible • Rational antimicrobial use, which seeks to im- antimicrobial use. The Coordinating mechanism will prove controlled access to antimicrobials and ensure that all these strategies are implemented. Fig 2: Strategic objectives

4.1 Strategic Plan and Strategic Objectives for AMR in Zimbabwe

4.1.1 Strategic Objective 1 – Education, training key AMR messages reach and resonates with all and awareness: To raise awareness and educate sectors and corners of the country. In coming up the population, professionals and policy makers with the training and awareness program for AMR on AMR both the formal and informal systems of informa- tion dissemination will be utilized. The formal ap- Developing and implementing a home-grown train- proach will encompass all the national educational ing and awareness program is key to ensuring that and training programs, which are well structured in THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 18 terms of content and the way they are delivered, mation will be of common importance to human, which are aimed at developing specific competen- animal and ecosystem health. This multi-sectoral cies or skills relevant to AMR. Informal approaches initiative encompasses laboratories from the Min- will also be used to relay key messages in simple istry of Health and Child Care (MoHCC), Ministry language that is understandable to all individuals of Agriculture, Mechanisation and Irrigation De- regardless of social, economic or educational sta- velopment (MAMID), the Ministry of Environment, tus. Zimbabwe is well advanced in terms of having Water and Climate (MEWC), National Biotechnol- access to modern forms of communication such as ogy Authority, City Health laboratories and private print, broadcast, audio and electronic communica- laboratories. AMU information is also lacking and tion media. However, individuals in different parts this new surveillance will include processes for col- of the country do not all have equal access to these lecting antimicrobial use data. communication channels. This disparity in access will be considered when developing the AMR train- Specific objectives for surveillance are to: ing and awareness strategy and plan. 1. Strengthen diagnostic laboratory capacity to Specific objectives for education and awareness are: improve healthcare professionals’ ability to make informed AMU decisions. 1. To improve awareness and understanding of AMR for the public, professionals and policy 2. Integrate the surveillance for humans, ani- makers. mals and the environment into a ‘One Health’ integrated surveillance system. 2. To strengthen the knowledge of human, ani- mal and environment health professionals 3. Establish an AMU monitoring system for anti- through improved curricula. microbials for human and animal use. 3. To educate farmers and animal keepers on AMR 4. Analyze and report surveillance data to sup- to support good antimicrobial use practices. port clinical and policy decision making in rel- evant sectors. 4. To strengthen the knowledge of school chil- dren on AMR at primary, secondary and ter- 5. Strengthen capacities for generating and ana- tiary level education. lysing AMR/AMU data to inform policy develop- ment, better targeting of interventions and man- The activities to achieve these strategic objectives agement decisions and to monitor progress. are described in more detail in the operational plan in section 3. The activities to achieve these strategic objectives are described in more detail in the operational plan in section 3.

4.1.2 Strategic Objective 2 – Surveillance: Improve detection and understanding of the AMR and antimicrobial use patterns and trends 4.1.3 Strategic Objective 3 – Infection through surveillance prevention & control, good animal husbandry Surveillance is important to detect the magnitude of and biosecurity: Reduce the need for AMR, and help to monitor trends in space and time. antimicrobials by improving IPC, animal Sound survey designs backed by laboratory testing health and management practices including are important tools in detecting AMR. Embracing biosecurity, WASH and immunisation the ‘One Health’ approach will help to gain efficien- Existing biosecurity measures, good farm manage- cies by reducing duplicative functions on the work ment practices and national IPC programs need to be of a similar nature for the same end. AMR infor- strengthened. Biosecurity is defined by OIE as “The THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 19 implementation of practices that create barriers in or- 4. Strengthen and expand vaccination programs der to reduce the risk of the introduction and spread of in animals and humans to improve prevention disease agents”. The three principles of biosecurity are and control of disease, and reduce AMU segregation, cleaning, and disinfection; where segre- 5. Reduce the transmission of infectious dis- gation is the creation and maintenance of barriers that eases in communities, health-care centers, limit the potential opportunities for infected animals veterinary and plant facilities through effective and contaminated materials to enter an uninfected water, sanitation and hygiene practices, and site. Improvement in animal health management prac- provision of appropriate facilities. tices includes farm facilities and movement controls, documentation of treatment provided to animals, the The activities to achieve these strategic objectives provision of appropriate care to sick animals and the are described in more detail in the operational plan prevention of illegal cross border movements. in section 3. The purpose of IPC in health care as defined by WHO, is “to prevent the occurrence of health-care 4.1.4 Strategic Objective 4 – Rational use of an- associated infections (HAIs) in patients, health-care timicrobials: Improve controlled access and op- workers (HCWs), visitors and other persons associated timise the use of antimicrobials in humans and with health-care facilities”(WHO 2009). Core compo- animals nents of an IPC program include IPC management structures and human resources such as training, pro- The availability of antimicrobials according to the gram staffing and occupation health support and IPC National Standard Treatment Guidelines (STGs) and guidelines that describe IPC activities such as hand Essential Medicines List, which are based upon the hygiene, standard and transmission based precau- current pathogen resistance patterns, is critical to tions, waste and linen management, environmental patient outcomes. Robust regulatory and medicine cleaning, disinfection processes and surveillance ac- management systems, including procurement, dis- tivities. Infections can also be prevented by effective tribution and dispensing systems, are needed to vaccination programs and by improving water, sanita- support access to safe, effective and affordable anti- tion and hygiene practices, and availability and acces- microbials and remove incentives for illegal dispens- sibility at community level. ing and poor quality medicine sales. Specific objectives for Infection, prevention and con- Access and availability of certain key antimicro- trol, good animal husbandry and biosecurity are: bials to animal keepers should be maintained and expanded and the necessary control mechanisms 1. Strengthen the existing biosecurity measures on implemented to prevent irresponsible use. An impor- hatcheries, farms, aquaculture establishments, tant element will be on-going education and aware- slaughter houses, and food processing estab- ness of key individuals involved in the distribution lishments etc., for pathogen risk reduction and administration of antimicrobials in animals. In 2. Improve movement controls of animals and addition, a sound regulatory environment that con- animal products, and border control mecha- trols and enforces the responsible use of antimicro- nisms to reduce trans-boundary animal dis- bials in humans, animals and the environment is es- ease occurrence transmission sential to the effective control of AMR. 3. Track and reduce the burden of health-care as- Specific objectives for rational use of antimicrobials are: sociated infections (HAIs) through improving IPC practices in all health care facilities in Zimbabwe 1. Improving access to quality assured antimi- crobials to animal keepers by increasing ac- THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 20 cess points for the sale and provision of anti- which are termed as short to medium-term plans to be microbials. implemented in the face of the current problem. 2. Strengthening control of antimicrobials and The long-term strategies need stronger collaboration their use in animal health by farmers and para from local, regional and international research institu- veterinarians without limiting access. tions as they require vast amounts of resources and time. 3. Implementing sustainable supervision, audit Short to medium term (1-5 years) investment and and feedback mechanisms in health facilities research needs by having functional medicines therapeutic committees in health institutions to ensure Local collaboration linking human-animal-environment appropriate antimicrobial use by prescribers. research activities is required in the following areas: • Support research on the model of transmis- 4. Ensuring that Standard Treatment Guide- sion between organisms and the transmis- lines (STG’s) and the Essential Medicines List sion of resistant bacteria among different (EML) reflect the current resistance patterns reservoirs (human-animal-environment). and pathogens in humans and animals. 5. Ensuring adequate supplies of quality assured • Conduct research to understand the capacity essential antimicrobials at various levels of hu- building needs such as human & financial man and animal health delivery systems. resources. 6. Controlling public access to prescription Long term investment and research needs only antimicrobials at the point of the phar- • Innovative diagnostic tools especially AMR macy and veterinary medicine general dealers rapid diagnostic tools (RDT’s) (VMGDs). • User-friendly and affordable vaccines and 7. Strengthening regulations to ensure appropri- new vaccines ate use of antimicrobials in animals. • New medicines, i.e. antibiotics 8. Promoting stewardship and pharmacovigi- lance in the use of antimicrobials. • Alternative therapies (complementary medi- cines, probiotics, etc.) The activities to achieve these strategic objec- tives are described in more detail in the opera- Specific objectives for Investment, Research & tional plan in section 3. development are: 1. To ensure sustainable investment in counter- ing AMR through implementing the NAP.

4.1.5 Strategic Objective 5 – Sustainable Investment into AMR interventions and 2. Develop innovate modern diagnostics, vac- research into new antimicrobials and cine and alternative therapy to AM. alternatives to antimicrobials The interventions to achieve these strategic objec- There is a need to develop the economic case for sus- tives are provided in the tables below and described tainable investment that takes into account the need for in more detail in the operational plan in section 3. increased investment in new diagnostic tools, vaccines, medicines and other interventions. The proposed ac- tivities are divided into short-term (1-2years), medium- term (2-5 years) and long-term (>5 years) research strategies. This plan outlines the immediate actions, THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 21

5.0 OPERATIONAL PLANS Below are the detailed operational activities, time frames and indicators for monitoring the achievement of the strategic objectives described above in the strategic plan. Time frames for completion of these activities have been divided into short term (within the next 2 years), medium term (within the next 5 years) and long term (greater than 5 years).

5.1 Strategic objective 1 – Education, training and awareness The four key pillars of the strategy are: • Surveillance of AMR and AMU patterns in animals, humans and crops. • Prevention, which will reduce the need for antimicrobials through effective IPC, farm biosecurity and good farm practices, WASH and immunisation • Rational antimicrobial use, which seeks to improve controlled access to antimicrobials and to optimise responsible use in animals and humans • Investment in research and development which seeks innovative ideas of alternatives to antimicrobials or quicker diagnostic techniques. Finally, the implementation of the Zimbabwe NAP depicts a strong inter-sectoral coordinating mechanism as its foundation and has its roof which is overarching and cross-cutting indicating the need to raise awareness and educate the public, professionals and policy makers on AMR and responsible antimicrobial use. The Coordinating mechanism will ensure that all these strategies are implemented. STRATEGIC OBJECTIVE: To improve awareness and understanding of AMR for the public, professionals and policy makers Intervention Activities Responsibility Timeframe

1.1 Develop a 1.1.1 Review existing communication and awareness strategies. TWG 1st year comprehensive national 1.1.2 Carry out an assessment on existing KAP (knowledge representatives communication and attitudes and practices) with animal keepers, farmers and veterinary awareness plan extension workers in rural communities, key-informant interviews.

1.1.3 Utilise results from the existing KAP and additional KAP including the national AMR situational analysis to inform on gaps and areas of strengthening.

1.1.4 Draft a national communication and awareness plan to cover topics including: AMR, AMU, IPC, biosecurity and animal health management, food security and safety, WASH and hand washing, stewardship, prescribing and treatment guidelines/practices, enforcement, waste disposal, surveillance, residues, and testing methods for humans and animals using various channels.

1.1.5 Pilot draft national communication and awareness plan in small cohorts.

1.1.6 Adjust national communication and awareness plan based on the results of pilot study.

1.1.7 Validation meeting to adopt final national communication and awareness plan. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 22

1.2. Roll-out of 1.2.1 Host a stakeholder sensitisation meeting on the approved Fluoroquinolone 1st – 2nd the national AMR plan (i.e. ministries of health, agriculture, environment, education, AMR core group, year communication and drug authority, media, enforcement, farmer organizations, MoHCC, TWG’s awareness plan professional associations, clinicians, nurses, pharmacists), hospital CEOs/associations, university heads, FAO WHO, OIE, NGOs, faith based organizations, provincial reps).

1.2.2 Review existing and produce Information, Education and Communication (IEC) materials.

1.2.3 Training of trainers (in-service training).

1.2.4 Cascading of training to frontline cadres (nurses and extension staff - veterinary).

1.2.5 Disseminating AMR information as identified in the communications plan (will include stewardship, IPC, good practices, animal health management, biosecurity, food safety etc) (channels include online, newspaper, radio, television, fliers, road shows, etc.) (target audiences i.e public, students, health professionals, regulators).

1.2.6 Engage Civil Society Organisations (CSOs) and development partners to mainstream AMR into programmes.

1.2.7 Use of champions in influencing AMR activities and attitudes in all relevant sectors (see champion creation below).

1.2.8 Organise activities for World Antimicrobial Resistance Awareness Week.

1.2.9 Presentations on AMR during other commemorative days e.g, world TB day, hand hygiene day, World Veterinary Day, etc.

1.3. Identify and 1.3.1 Establish criteria to select AMR champions and specify role of AMR core group; 2nd year capacitate opinion the champions. TWGs leaders to champion

1.3.2 Identification of AMR champions/opinion leaders. the AMR agenda in all sectors. 1.3.3 Capacitation of AMR champions and consensus building.

1.4. Advocate on IPC 1.4.1 Hold field days to promote good hygiene practices and MoHCC Ongoing in human health, sanitary measures. and good animal

1.4.2 Hold meetings at the community level e.g. women’s groups, health management church organisations, farmer groups. and biosecurity at community level. 1.4.3 Train Village Health workers in IPC and AMR; and train para veterinary auxiliaries in biosecurity and AMR.

1.5. Promote 1.5.1 Run education and awareness campaigns. MoHCC and Ongoing behavioural change relevant

1.5.2 Commemorate hand hygiene days. and practices that instil authorities good hygiene in the 1.5.3 Mobilise resources for WASH facilities and activities. community through access to effective water, sanitation and hygiene facilities. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 23 STRATEGIC OBJECTIVE: To strengthen the knowledge of human, animal, environment health professionals and feed manufacturers through improved curricula and educate farmers on AMR to support good prescribing practices Intervention Activities Responsibility Timeframe

1.6 Strengthen curricula 1.6.1 Engage stakeholders and advocate for curricula review and TWG/Core group 1st – 2nd for human health update. supporting year professionals (including review panels,

1.6.2 Review and update tertiary educational curricula on AMR, doctors, nurses, curricula AMU, IPC, biosecurity, biosafety, WASH, stewardship, prescribing pharmacists, laboratory committees and treatment guidelines, enforcement, surveillance, and lab scientists, health at universities 1st – 2nd testing for humans and animals. promotion students, and training year public health students). 1.6.3 Review and update educational curricula at professional in- institutions in service training levels for human health to strengthen AMR, AMU, collaboration IPC, biosecurity, biosafety, WASH, stewardship, prescribing and with MoHCC treatment guidelines, enforcement, surveillance, and lab testing for humans and animals. MoHCC, NBA,

1.6.4 Develop training modules in IPC requirements to reduce HPA and its transmission of MDRO to be used for training of health workers at Councils, Min pre- service and in-service level. of Higher

1.6.5 Enforce continuous professional development (CPD) on AMR, and Tertiary AMU, IPC, biosecurity, biosafety, WASH, stewardship, prescribing Education, and treatment guidelines, enforcement, surveillance, and lab Vocational testing for humans and animals Traning Schools

1.6.6 Formalize and strengthen mentoring and supervisory program for junior doctors in the public sector

1.6.7 Formalize and strengthen mentoring and supervisory program for junior pharmacists in the public sector

1.6.8 Formalise a training programme for all nurses at primary health-care (PHC) on selection of antimicrobials for use at the facilities

1.6.9 Strengthen mentoring and supervisory program for prescribing nurses in the public sector

1.7. Strengthen curricula 1.7.1 Review and update tertiary educational curricula TWG/Core group for animal health AMR, AMU, IPC, good animal health management practices supporting professionals. and biosecurity, WASH, stewardship, prescribing and treatment review panels, guidelines, enforcement, surveillance and lab testing for humans curricula 1st – 2nd and animals committees year at training

1.7.2 Review and update educational curricula at professional institutions in in-service training levels for animal health to strengthen AMR, AMU, collaboration IPC, good animal health management practices, biosecurity, WASH, with MoHCC and stewardship, prescribing and treatment guidelines, enforcement, MoA, MoHTE surveillance and lab testing for animals Ongoing and Vocational

1.7.3 Formalize and strengthen mentoring program for junior Training Schools veterinarians in the public sector

1.7.4 Design and integrate AMU and AMR into continuous DVS professional development of veterinarians

1.7.5 Enforce continuous professional development (CPD) on AMR, AMU, IPC, good animal health management practices, biosecurity, WASH, stewardship, prescribing and treatment guidelines, enforcement, surveillance, and lab testing for animals DVS THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 24

1.7.6 Conduct a KAP survey on IPC, good animal health management practices, and biosecurity among veterinary personnel in private and government sectors/ environmental officers/ food safety officials/wildlife veterinarians

1.7.7 Conduct CPD training in biosecurity issues in relation to AMR for veterinary personnel in private and government sectors/ lab scientists/Agritex officers/ environmental health technicians and officers/meat inspectors/veterinarians/veterinary nurses/ extension workers

1.8. Enhance the 1.8.1 Review training guidelines for shop owners of outlets for MoHCC Ongoing knowledge of animal veterinarian products keepers on appropriate

1.8.2 Provide education for the VMDGs with an AMR focus use of antimicrobials through train the trainer sessions

1.8.3 Reinforce by refresher course, education and awareness for the VM outlets for veterinarian products with an AMR focus through train the trainer sessions

1.8.4 Design and execute awareness campaigns to educate (smallholder and commercial) farmers on prudent use of antibiotics in production of food animals and the threat of AMR arising from misuse/overuse

1.9. Strengthen curricula 1.9.1 Review and update tertiary educational curricula TWG/ 1st – 2nd for environmental health AMR, AMU, IPC, biosecurity, WASH, stewardship, prescribing and CORE group year professionals. treatment guidelines, enforcement, surveillance and lab testing for supporting humans and animals. review panels, curricula

1.9.2 Review and update educational curricula at professional committees in-service training levels for human health to strengthen AMR, at training AMU, IPC, good animal health management practices, biosecurity, institutions in WASH, stewardship, prescribing and treatment guidelines, collaboration enforcement, surveillance, and lab testing for humans and animals. with MoE

1.10 Enhance 1.10.1 Review regulations of the antibiotics that are used in stock Stock feeds knowledge of stock feed feeds. Manufacturing manufacturers, farmers Association,

1.10.2 Coordinate and monitor the antimicrobials used in feeds. and animal keepers on SARS. stock feed guidelines 1.10.3 Train farmers and animal keepers on withdrawal periods for certain stock feeds.

1.10.4 Train feed manufacturers on regulations and guidelines concerning antibiotics in stock feeds. STRATEGIC OBJECTIVE: To strengthen the knowledge of school children on AMR at primary, secondary and tertiary level education Intervention Activities Responsibility Timeframe

1.11 Develop curricula to 1.11.1 Meet with stakeholders including MoH and Ministry of TWG, Core 1st – 2nd train teachers in college/ Primary and Secondary Education (MoPSE) to emphasize need for Group year university curricula. MoE; curricula

1.11.2 Support MoPSE to develop the curricula-information, dev unit review with stakeholders, and revise. MoHCC, school

1.11.3 Disseminate curricula-information to lecturers, teaching health masters training colleges, and train the teachers in schools. TWG, Core

1.11.4 Update curricula periodically. group/MoE THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 25

1.12 Review, revise or 1.12.1 Meet with stakeholders including MoH and MoPSE to TWG, Core 1st – 2nd develop curricula for emphasize need for curricula. Group of AMR year primary/secondary MoPSE; school

1.12.2 Support MoPSE to develop the curricula-information, students (also tie into health masters review with stakeholders (MPSE and curricula development unit), awareness plan). and revise (TWG/CORE group/MoPSE).

1.12.3 Disseminate curricula-changes to lecturers, teaching MoPSE training colleges train the teachers in school (MoPSE) school health Ongoing masters – health experts.

1.12.4 Train teachers in the field on the curricula.

1.12.5 Update periodically.

5.2 Strategic objective 2 – Surveillance STRATEGIC OBJECTIVE: Strengthen diagnostic laboratory capacity to improve the healthcare professionals’ ability to make informed antimicrobial use decisions. Intervention Activities Responsibility Timeframe

2.1 Assess laboratory 2.1.1 Use a laboratory assessment tool (e.g. ATLASS) to assess the Lab surveillance 1st – 2nd capacity to carry out AMR human laboratory capacity to carry out AMR susceptibility testing. TWG year susceptibility testing

2.1.2 Use a laboratory assessment tool (e.g. ATLASS) to assess the in all relevant sectors veterinary laboratory capacity to carry out AMR susceptibility including residue testing. testing.

2.1.3 Use a laboratory assessment tool to assess the environment central laboratory capacity to carry out AMR susceptibility testing.

2.1.4 Use a laboratory assessment tool to assess the food safety laboratories’ capacity to carry out AMR susceptibility testing.

2.1.5 Use a laboratory assessment tool to assess laboratories’ capacity to carry out residue testing.

2.2 Develop budgets 2.2.1 List the required equipment. Lab surveillance 1st – 2nd and plans for gap TWG year

2.2.2 Ascertain the required HR. filling including equipment, human 2.2.3 List the consumables required. resources and 2.2.4 Ascertain the field services required consumables

2.3 Harmonize SOPs 2.3.1 Harmonise SOPs using international standards (e.g. CLSI, Lab Surveillance 1st – 2nd for testing samples for EUCAST) for all sectors through meetings and iterative drafts. TWG. MLCSCZ, year AMR and for organism CVS

2.3.2 Implement SOPs. identification (One Health) 2.3.3 Validate methods for antimicrobial residue testing

2.4 Upgrade 2.4.1 Site visits to confirm installation of equipment and Lab surveillance 1st – 2nd laboratories as receipt of supplies TWG. year needed

2.4.2 Train lab personnel on the lab surveillance system.

2.4.3 Train lab personnel on residue testing. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 26

2.5 Collect and test 2.5.1 Design statistically sound surveys for AMR Government 2nd – 5th routine samples in all Hospital year

2.5.2 Design surveys and test for antimicrobial residues sectors Laboratories and

2.5.3 Collect biological test samples and test (blood, tissue, some private urine, stool, cerebral spinal fluid, swabs and aspirates). labs

2.5.4 Analyse results and generalise interpretations

2.5.5 Collect and test samples in the animal labs and these are DVS labs – MOA clinical and post mortems samples – domestic and wild animals, milk samples, meat samples from abattoirs, imported animal products Government Analyst

2.5.6 Collect and test samples in the food lab and these are Laboratory (GAL) meat and meat products, milk and milk products, water, ready to eat food, poultry and poultry products, fish and fish products, cereals and condiments.

2.5.7 Collect and test samples of potable, raw and wastewater in the environment for AMR and AM residues EMA and City of

2.5.8 Survey and test samples of beef, poultry, eggs, pork, Harare lab, DVS dairy, mutton, chevron, and fish for AM residues

2.5.9 Survey and test honey for adulteration and antibiotic residues. GAL and DVS

2.6 Progress toward 2.6.1 Develop/Implement quality management systems (QMS) All laboratories, Ongoing accreditation of all in all laboratories selected for accreditation coordinated by laboratories (ISO) NMRL, CVL

2.6.2 All equipment in the bacteriology laboratories to have service contracts.

2.6.3 Validate the bacteriology equipment.

2.6.4 Validate all bacteriology tests.

2.6.5 Subscribe to an external quality assurance (EQA) program. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 27 STRATEGIC OBJECTIVE: Strengthen diagnostic laboratory capacity to improve the healthcare professionals’ ability to make informed antimicrobial use decisions. Intervention Activities Responsibility Timeframe

2.7 Combine human 2.7.1 Identify priority organisms for reporting. NMRL (MoHCC) 1st – 2nd AMR surveillance into year

2.7.2 Identify appropriate antibiotics to be reported on. IDSR reporting systems

2.7.3 Add AMR reporting to standard IDSR policy and implement.

2.7.4 Monitor AMR reports and add to annual reporting for Core Group.

2.7.5 Report AMR trends to the National Health Information System (NHIS), GLASS, CDDEP, Lab surveillance TWG.

2.8 Animal surveillance: 2.8.1 Identify priority organisms for reporting (including CVL/DVS 1st – 2nd Establish AMR animal species and source) year surveillance within

2.8.2 Identify appropriate antibiotics to be targeted by existing disease surveillance system. notification system for animals 2.8.3 Communicate reporting needs to all laboratories.

2.8.4 Establish reporting systems and standards for analysis.

2.8.5 Report AMR trends to the Vet Epidemiology Department, CDDEP, Lab surveillance TWG.

2.9 Add food and 2.9.1 Develop organism/antibiotic targets drawing on human GAL (MoHCC) 1st – 2nd potable water testing and animal targets and local year for AMR into existing authorities,

2.9.2 Have a national database for foodborne infections. potable water and food Environmental safety testing. 2.9.3 Report to the National Health Information System (NHIS), Health and GLASS, CDDEP and the lab surveillance TWG. City Health Department

2.10 Establish an active 2.10.1 Develop a targeted surveillance plan DVS, Academia >5 years surveillance system,

2.10.2 Train veterinary field personnel. in selected farming communities (e.g. 2.10.3 Train environmental field technicians resettled farming 2.10.4 Train human health personnel sector, informal urban livestock keepers; feed 2.10.5 Determine the needed capacity for sample manufacturers) transportation

2.10.6 Determine sampling plan

2.10.7 Implement sampling process

2.11 Integrate animal, 2.11.1 Establish outline of a report for integrated AMR AMR core group 1st – 2nd human, crop and surveillance reporting year environmental AMR

2.11.2 Draw data from all sources (as above) and generate surveillance through a report single report

2.11.3 Publish report annually by AMR Core Group THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 28 STRATEGIC OBJECTIVE: Establish an antimicrobial use (AMU) monitoring system for human and animal use Intervention Activities Responsibility Timeframe

2.12 Determine 2.12.1 Develop and adopt appropriate tools to monitor AMR Core group 1st – 2nd surveillance system for antimicrobial consumption in the human health sector. year each section on AMU

2.12.2 Determine existing sources of AM consumption

2.12.3 Train data collectors on AMU consumption tools.

2.12.4 Collect human consumption data

2.12.5 Develop and adopt appropriate tools to be used for monitoring antimicrobial consumption in the animal health sector.

2.12.6 Determine existing sources of AM consumption

2.12.7 Train data collectors on AMU consumption tools.

2.12.8 Collect data on food animals.

2.12.9 Develop and adopt appropriate tools to be used for monitoring antimicrobial consumption in the crop sector.

2.12.10 Determine existing sources of AM consumption.

2.12.11 Train data collectors on AMU consumption tools.

2.12.12 Collect data on crops.

2.12.13 Integrate animal, crop and human AMU data into single report and combine with AMR data report annually. STRATEGIC OBJECTIVE: Strengthen diagnostic laboratory capacity to improve the healthcare professionals’ ability to make informed antimicrobial use decisions. Intervention Activities Responsibility Timeframe

2.13 Modernize, 2.13.1 Conduct a needs assessment of IT system for AMR and AMR core group. 2nd – 5th upgrade and maintain antimicrobial use year central information

2.13.2 Integrate into the current IT administrative structure of management systems NMRL, CVL, EMA, responsible organisations. to handle AMR and GAL, MCAZ AMU data, with 2.13.3 Determine resources needed to maintain a central interoperability between information system systems and access for CVL/DVS

2.13.4 Expand provincial level (and eventually district level) official users. input into veterinary information management systems on AMR and AMU, as a component of general expansion EMA,

2.13.5 Expand provincial level (and eventually district level) Government input into food safety and environmental central information analyst management systems

2.14 Develop annual 2.14.1 Extract all data from each data source MoHCC, DVS, 2nd – 5th One Health report on City Health, EMA, year

2.14.2 Analyse data AMR, AMU (aimed at NBA high-level policymakers, 2.14.3 Compile report and send to stakeholders for inputs donors and relevant 2.14.4 Publish report annually international organization reporting systems: WHO, OIE, FAO, CDDEP.

2.15 Present information 2.15.1 Meet with policy makers annually with surveillance Core AMR group 1st – 2nd to policymakers in reports and proposed EML and STG revisions. year appropriate formats

2.15.2 Issue a yearly bulletin with significant findings. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 29

5.3 Strategic objective 3 - Infection prevention and control and biosecurity STRATEGIC OBJECTIVE: Strengthen the existing biosecurity measures on hatcheries, farms. slaughter houses and food processing establishments to prevent, reduce and contain pathogens to improve livestock productivity, animal welfare, food security and food safety Intervention Activities Responsibility Timeframe

3.1 Review and update 3.1.1 Produce guidelines on good animal health management DVS/MAMID, 1st – 2nd current biosecurity practices, biosecurity incorporating AMR issues NBA year guidelines in relation

3.1.2 Hold a stakeholder consultation to ensure suitability for to AMR and relevance different farming scales and systems to small scale farmers and review current 3.1.3 Adopt, adapt for literacy/translation and dissemination legislation in relation to 3.1.4 Review current legislation in relation to acts relevant biosecurity and AMR to veterinary/animal production industry to update in relation to biosecurity requirements and AMR

3.1.5 Disseminate biosecurity guideline through relevant Ministries, Government Departments and Associations

3.2 COnduct a risk 3.2.1 Conduct a baseline survey to identify risk factors MoHCC/Local 1st – 2nd assessment of meat associated with the transmission of MDR/DR pathogens authorities year industries to identify

3.2.2 Use baseline survey to adapt biosecurity guidelines as pathogens to inform required appropriate food safety and biosecurity measures

3.3 Measure the extent 3.3.1 Conduct a baseline survey stratified according to outlet NIHR, BRTI & 1st – 2nd of MDR/DR bacteria types supermarkets, vendors, farmers markets, of MDR/DR bacteria GAL year contamination of food levels in: and food handlers in • Dairy products food sales outlets to inform biosecurity • Meat measures and food • Eggs safety • Vegetables • Fish and fish products • Other animal derived products

3.3.2 Use baseline survey to adapt biosecurity guidelines as required

3.4 Ensure that the 3.4.1 Develop a sampling and inspection plan for regular DVS/MAMID 3rd – 5th regulatory body inspections of hatcheries and farms year inspects hatcheries,

3.4.2 Assess staff and transport requirements to carry out laboratories, farms regular inspections and slaughter houses, and food processing 3.4.3 Implement sampling and inspection plan establishments THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 30 STRATEGIC OBJECTIVE: Improve movement controls of animals and animal products and border control mechanisms to reduce trans boundary animal disease Intervention Activities Responsibility Timeframe

3.5 Strengthen border 3.5.1 Create and Conduct Awareness campaigns including DVS 1st – 2nd post controls in relation posters on risks and impact of illegal import of animal derived food year to biosecurity products

3.5.2 Strengthen the monitoring system for personnel at border posts

3.5.3 Increase penalties for offenders Ministry of Home Affairs,

3.5.4 Improve quarantine and testing (POCT) at main NBA border posts and esablish incineration and disposal facilities for condemned materials STRATEGIC OBJECTIVE: Track and reduce the burden of health care associated infections (HAIs) through improving IPC practices in all health care facilities in Zimbabwe Intervention Activities Responsibility Timeframe

3.6 Revise IPC 3.6.1 Review 2013 IPC guidelines in relation to AMR NIPCC (MoHCC) 1st – 2nd guidelines in relation year

3.6.2 Develop health facility based SOPs and IEC materials to AMR using evidence- from udpated guidelines for reduction of transmission of MDRO based IPC practice

3.7 Improve IPC 3.7.1 Disseminate updated IPC training to all relevant training NIPCC (MoHCC) 1st – 2nd practices to reduce institutions year transmission of MDRO

3.7.2 Continuing in-service training on IPC at health vacilities through pre-service, using updated modules in-service and CPD programmes

3.8 Strengthen IPC 3.8.1 Update MoHCC IPC site support visit monitoring tools in NIPCC M&E and 1st – 2nd site support visits in relation to IPC surveillance year relatino to AMR TWG

3.8.2 Include AMR/IPC issues in IPC site support visits

3.9 Establish a National 3.9.1 Strengthen health care associated infection (HAI) NIPCC, TWG for 1st – 2nd HAI surveillance and feedback systems at the facility level including Surveillance and year collection of data on common HAI pathogens and their M&E susceptibility patterns

3.9.2 Develop a link to the NHIS for collection of data on HAIs, HAI pathogens and susceptibility patterns to inform the National IPC Policy and Strategic Plan THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 31 STRATEGIC OBJECTIVE: Track and reduce the burden of health care associated infections (HAIs) through improving IPC practices in all health care facilities in Zimbabwe Intervention Activities Responsibility Timeframe

3.10 Increase 3.10.1 Ensure availability of adequate vaccines and supplies for DVS and MoHCC Ongoing vaccine coverage in animals and humans populations/herds

3.10.2 Conduct outreach services for hard to reach communities for animals and humans

3.10.3 Conduct mass immunisation/vaccination campaigns for animals and humans

3.10.4 Conduct vaccinations for animals at dip-tanks in areas where previously not done

3.10.5 Develop IEC materials and health education messages for animal vaccination in local languages to motivate and mobilize participation

3.10.6 Advocate and mobilize to increase vaccine uptake in animals using VHWs, agriculture and extension workers, radio and TV< and mobile technology, Farmer’s Union meetings. “One Health Field Days” field days, and agriculture shows.

3.11 Improve 3.11.1 Advocate and conduct community mobilisation using DVS and MoHCC Ongoing adherence to VHWs, agriculture extension workers, and health education scheduled vacccination through radio, TV and mobile technology. in humans

3.12 Develop user 3.12.1 Use pathogen surveillance data to inform additional DVS and MoHCC >5 years friendly and effective vaccination programmes for improved animal health. vaccines against

3.12.2 Conduct continuous reviews of infection surveillance protozoa and ricketsial data in humans to expand the immunisaiton schedule to include parasites and different new vaccines where required populations/farms/ species/groups 3.12.2 Determine the cost benefit of new vaccines and that have shown determine funding sources effectieness in preventing infectious diseases STRATEGIC OBJECTIVE: Reduce the transmission of infectious diseases in communities, health, veterinary and plant facilities through effective water, sanitation and hygiene practices and provision of appropriate facilities Intervention Activities Responsibility Timeframe

3.13 Strengthen WASH 3.13.1 Conduct consultative stakeholder meetings to identify MoHCC and 1st – 2nd facilities and activities areas of focus for WASH relevant year in communities, health authorities

3.13.2 Conduct a situation analysis in communities and facilities facilities, veterinary and (human and non-human) plan facilities

3.13.3 Review and update the national WASH plan

3.13.4 Implement the updated WASH plan

3.13.5 Monitor implementation and address indentified gaps accordingly THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 32

5.4 Strategic Objective 4 - Rational use of antimicrobials STRATEGIC OBJECTIVE: Improve access to antimicrobials by animal keepers by increasing access points for the sale and provision of antimicrobials Intervention Activities Responsibility Timeframe

4.1 Increase access 4.1.1 Formalize the registration of veterinary paraprofessionals CVSZ 3rd – 5th points for quality under the Veterinary Professions legislation year assured over the counter

4.1.2 Make rules flexible for veterinarians to conduct services (OTC) antimicrobials by in ambulatory fashion in communal settings animal keepers

4.1.3 Train Animal Management and Health Centers (AMHC) for greater responsibility for veterinary supervised distribution of antimicrobials in the public sector

4.2 Formalize 4.2.1 Update current veterinary medicine registration MCAZ/DVS 2nd – 5th the appropriate guidelines to include the list of antimcirobials of beterinary year antimicrobials to importance for use in animals as per OIE recommendations while be used in animal safetuarding critically important antimicrobials for human use health against OIE

4.2.2 Create a veterinary Naitonal Medicine and Therapeutics Critically important Policy Advisory Committee to guide the development of STGs and Antimicrobials (CIA) EMLs Ongoing guidelines DVS-MCAZ-

4.2.3 Develop an EML for animal products in Zimbabwe AHICZ-CVSZ

4.2.4 Conduct a regular review of EML and STGs against AMR and AMU surveillance data STRATEGIC OBJECTIVE: Strengthen veterinary control of antimicrobials use by animal keepers and veterinary para professionals without limiting access Intervention Activities Responsibility Timeframe

4.3 Improve control 4.3.1 Strengthen enforcement on the restriction of access to MCAZ 2nd – 5th of antimicrobial use prescription AM preparations year through increased

4.3.2 Develop and implement a tool for monitoring the enforcement of CVSZ prescribing patterns/behavior of veterinarians, paravets and regulations MCAZZ farmers.

4.3.3 Strengthen post market surveillance on AMs which are on the market for animal use

4.3.4 Develop reuglations to enable the implementatin of OIE standards by veterinarians & veterinary paraprofessionals on the prudent use of antimicrobials

4.4 Development of One 4.4.1 Conduct stakeholder engagement in the formulation of AMR Core Group, 1st – 2nd Health Antimicrobial use guidelines and regulations for promoting optimal antimicrobial MAMID-DVS, year Guidelines for animal use and biosafety in animal food supply system LMAC, DRSS health

4.4.2 Develop guidelines on optimal antimicrobial use for Ongoing specific livestock production sub sectors (Poultry, pigs, fish, cattle, sheep and goats, etc.) and for the stock feed manufacturing industry (research species specific guidelines (STG’s) in other countries and OIE recommendations) THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 33

4.4.3 Develop simple antimicrobial use decision guidelines and policies for para professionals in the livestock health delivery system, for farmers and over the counter veterinary medicine retailers (veterinary medicine general dealers outlets)

4.4.4 Regularly review the guidelins to ensure their appropriateness STRATEGIC OBJECTIVE: Implement sustainable supervision, audit and feedback mechanisms in health facilities by having functional hospital medicines therapeutic committees in hospitals to ensure appropriate antimicrobial use by prescribers Intervention Activities Responsibility Timeframe

4.5 Ensure functional 4.5.1 Improve the governance process and review content of MoHCC (DPS) 1st – 2nd Hospital medicine guidance provided by the HMTC’s year therapeutics

4.5.2 Expand HMTC’s to hospitals without functioning committees (HMTC) at committees all levels of the health system 4.5.3 Expand the functions of district HMTCs to strengthen support provided to the PHC level

4.5.4 Formalize the reporting structure/system for reporting in relation to AMR of the HMTC to the MOHS DIretor of Pharmacy Services

4.6 Implement 4.6.1 Develop guidelines for HMTC’s to facilitate the MOHCC (DPS)/ 1st – 2nd sutainable supervision, implementation of AMS activities. HPA and its year audit and feedback respective mechanisms affiliate councils STRATEGIC OBJECTIVE: Ensure Standard Treatment Guidelines (STG’s) and Essential Medicine List (EML) reflect the current diseases and pathogens in humans and animals Intervention Activities Responsibility Timeframe

4.7 Regularly review the 4.7.1 Regularly review the EML against the WHO list for MoHCC (DPS, 3rd – 5th STG’s and EML humans NMTPAC) year

4.7.2 Regularly review the STGs taking into account the resistance patterns, disease burden and prevalence of infectious diseases

4.7.3 Incorporate AMR surveillance information into the review of the STG’s

4.7.4 Create an EML for animal health.

4.7.5 Create STGs for animal health

4.7.6 Review and update animal EML and STGs annually.

4.7.7 Develop biosafety guidelines for crops. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 34 STRATEGIC OBJECTIVE: Ensure adequate supplies of quality assured essential antimicrobials at various levels of human and animal health delivery systems Intervention Activities Responsibility Timeframe

4.8 Improve the 4.8.1 Advocate for the sustained funding of antimicrobials MoHCC (DPS) > 5 years affordability of in EML to improve access and reduce the financial burden on the antimicrobials patient 1st – 5th year

4.8.2 Donor coordination to cover more of the EML including antimicrobials

4.8.3 Advocate for implementation of Universal Health Coverage MCAZ

4.8.4 Investigate of the presence and extent of poor quality medicines including counterfeits and unregistered medicines and illegal medicine vendors (for animals and humans)

4.9 Ensure availability of 4.9.1 Strengthen the procurement cycle and supply chain for MoHCC (DPS) 3rd – 5th antimicrobials both human and animal AMs year

4.9.2 Strengthen forecasting processes based on improved antimicrobial use surveillance data

4.10 Ensure appropriate 4.10.1 Establish basic infrastructure for appropriate storage MoHCC (DPS) 3rd – 5th storage of antimicrobials of antimicrobials (esp. at rural clinics) e.g. for cold chains and year ambient temperature storage facilities

4.10.2 Establish appropriate storage at animal rehabilitation health centres (cold chain and ambient temp storage facilities) MAMID-DVS STRATEGIC OBJECTIVE: Control public access to antimicrobials at the point of the pharmacy and veterinary medicines general dealers (VMGDs) Intervention Activities Responsibility Timeframe

4.11 Improve access at 4.11.1 Strengthen awareness of pharmacists to comply with the MCAZ and 1st – 2nd pharmacies existing regulations on good dispensing practices of antimicrobials stakeholders year (activity

4.11.2 Capacitate the inspectors and strengthen the process coordinated of monitoring of compliance of pharmacists to antimicrobial by education dispensing (MCAZ) and awareness TWG) STRATEGIC OBJECTIVE: Strengthen regulations to ensure appropriate use of antimicrobials in animals Intervention Activities Responsibility Timeframe

4.12 Harmonise veterinary 4.12.1 Identify the responsible authorities for existing acts on MoHCC, 3rd – 5th acts on antimicrobial use animal health regulation and animal feeds. MAMID, EMA year and incorporate feeds as and ZRP,

4.12.2 Conduct a participtory stakeholder meeting to review per OIE guidelines +MCAZ existing regulatory practices and enforcement mechanism MCAZ/MoHCC,

4.12.3 Redraft existing legislation to harmonise regulations, NBA align with OIE guidelines and clarify roles and responsibilities of regulators in monitoring and enforcement of regulations

4.12.4 Capacitate regulatory authorities to implement and MoHCC, enforce harmonized regulatory framework MAMID-DVS, DRSS, NBA THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 35

5.5 Strategic Objective 5 - Investment into research and development STRATEGIC OBJECTIVE: To ensure sustainable investment in countering antimicrobial resistance through implementing the NAP Intervention Activities Responsibility Timeframe Short-term investment

5.1 Assess the 5.1.1 Conduct desk studies to identify th eextent & type of MoHCC (NIHR, 1st – 2nd investment required resistance in human, animals & environment. TMD), DVS, year for implementation EMA, NBA,

5.1.2 Basic study of the problems identified in relaiton to AMR of the national action Universities, plan based on the One 5.1.3 Establish an AMR Unit under the Research Council of Research Health approach, create Zimbabwe. institutions/ a plan to secure and use 5.1.4 Establish a collaborative research committee to approve AMR Core the required financing and regulate research on AMR & AMU in lines with the One Health Group approach under RCZ.

5.1.5 Conduct basic studies tracing resistance at the genetic level.

5.1.6 Study resistance mechanisms and identify sources and patterns of AMR spread

5.1.7 Monitoring and evaluation studies related to data findings

5.1.8 Research into alternatives to antimicrobials such as traditional medicine or probiotics

5.2 Pilot testing of 5.2.1 Ensure that 1% of the budget given to the institutions MoHCC, DVS, 1st – 2nd innovative ideas for is to be used for research & part of the funding to come from EMA + AMR year financing research and development partners. Charge companies importing antibiotics Core Group development and for 0.5% of total cost of (antimicrobials imported) for research. new market models to encourage investment and ensure access to new antimicrobial products. STRATEGIC OBJECTIVE: Develop innovative modern diagnostics tools, vaccines and alternative therapies to antimicrobials Intervention Activities Responsibility Timeframe

5.3 Develop and or 5.3.1 Develop innovative diagnostic tools. NIHR, DVS, EMA, > 5 years utilize innovative academia, DRSS,

5.3.2 Evaluate innovative modern diagnostic tools and diagnostic tools NBA, BRTI methods.

5.3.3 Adopt modern technologies in reporting laboratory diagnostic results.

5.3.4 Review existing diagnostic capacity of laboratories and identify of gaps.

5.3.5 Introduce rapid diagnostic tools.

5.3.6 Decentralize diagnostic centres to lower levels.

5.3.7 Adopt modern diagnostic methods. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 36

5.4 Develop the ability 5.4.1 Identify vaccine gaps NIHR, DVS, EMA, > 5 years for local production of academia, DRSS,

5.4.2 Determine local product requirements and business case zoonotic vaccines BRTI

5.4.3 Source funding for local product

5.5 Develop new 5.5.1 Collaborate with R&D institutions and pharmaceutical NIHR, TMD, DVS, > 5 years AM therapies and industry to determine new antimicrobial therapy EMA, academia, alternatives DRSS, BRTI

5.5.2 Identify ethno veterinary medicines of potential for all treatments

5.5.3 Identify traditional medicines of potential for alternatives

5.5.4 Establish funding and business case for the development of these alternatives

5.6 Establish Central 5.6.1 Review existing approval process for human and animals NIHR, TMD, DVS, Long term Regulatory platform for clinical trials EMA, academia, Clinical trial approval DRSS, BRTI

5.6.2 Determine collaboration potential and business case for a single regulatory platform

5.6.3 Support research into mode of transmission between organisms and humans, animals and environment interfaces THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 37

6.0 MONITORING AND EVALUATION

6.1 Approach and components of M&E Monitoring and evaluation (M&E) is required to as- • An assessment/survey of antimicrobial use in sess progress, to identify barriers to achieving results health services and farms, to assess compli- and remedial actions required and for accountabil- ance with treatment guidelines and access to ity. The approach to M&E of the NAP will be based appropriate medicines, is planned after 2 to 3 on the following years unless it can be done through supervi- sion/audit. • For each pillar of the strategy, the relevant TWG will be responsible for planning the mon- • Qualitative assessment and analysis will also itoring, including defining indicators in detail, be required, e.g. to review whether the quality identifying how and how often they are col- of surveillance reports is improving and how lected, and baselines; they may prioritise the this affects trends in AMR; to review findings most important indicators. As implementation from supervision reports. proceeds, the TWGs will review implementa- tion process (whether planned activities have • After 5 years of implementation, an indepen- been done, reasons for lack of progress); moni- dent evaluation team will be engaged to eval- tor outputs and effects, and analyse the results. uate the whole process. • At least once a year, the TWGs will report on • Costs of M&E will be included in costing and progress to the AMR Core Group and Advisory budgeting of the NAP. Committee. Monitoring indicators i.e. outputs, established are • KAP studies will be repeated after 3 years to as- there to ensure that the activities of the NAP are sess progress in changing knowledge, attitudes implemented whereas the evaluation indicators and practices (for target groups where there which are the outcomes will determine the impact have been interventions to change behaviour). of implementation of that strategic objective Pillar Strategic objective Monitoring mechanisms/ Evaluation of impact indicators indicators (Output) Overall NAP implementation Monitor that the activities of Evaluate the impact of the NAP are implemented the strategic objective implementation 1. Evaluation, training To improve awareness and • Knowledge and awareness • Improved understanding and and awareness understanding of AMR activities conducted on awareness of AMR issues as AMR for the general public demonstrated by KAP study results (including farmers) • Knowledge and awareness activities conducted on AMR for the health care and animal health professionals THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 38 Strengthen the knowledge • # of curricula for human • Improved understanding and of human, animal and healthcare professionals awareness of AMR issues as environment health containing updated AMR demonstrated by the survey professionals through components tool for professional knowledge improved curricula and study results—human healthcare • # of curricula for animal educate farmers on AMR to professionals professionals containing support good prescribing updated AMR components • Improved understanding and practices awareness of AMR issues as • # of curricula for demonstrated by the survey environmental health tool for professional knowledge professionals conaining study results—animal healthcare updated AMR components professionals (Curricula should contain at least • Improved understanding and the following AMR, AMU, AMS, IPC, awareness of AMR issues as Biosecurity, WASH components) demonstrated by the survey tool for professional knowledge study results—environmental health professionals • Compliance with treatment guidelines in animals Strengthen the knowledge • AMR aspects incorporated • Improvement in awareness and of school children on AMR into the school curricula for understanding of AMR issues as at primary, secondary and all levels (e.g. AMR, AMU, measured by a KAP surveys for tertiary level education WASH) students and teachers and parents of students, measure change in knowledge on AMR • Reduction in AMU at community level—Defined Daily Doses (DDDs) Strengthen the • DRSS and SARS to carry out • Reduced antimicrobial use in knowledge of stockfeed level of antibiotic tests in stockfeeds. manufacturing companies stockfeeds for both local and • Compliance of stockfeed concerning antimicrobial imported stockfeeds guidelines use in stockfeeds 2. Surveillance and Strengthen diagnostic • % of labs reporting • % of labs accredited by external research laboratory capacity to susceptibility results out of quality assurance program out of improve the healthcare all labs identified to provide all labs—Labs are accredited by professionals’ ability diagnostic services an accreditation body in a staged to make informed process starting with referral antimicrobial use decisions. hospitals, then district hospitals, and then public and private Integrate the surveillance • Human surveillance fully • Annual integrated One Health for animals, humans and integrated into IDSR system report on AMR the environment into a • Animal surveillance fully One Health surveillance integrated into existing approach disease notification system • Water and food safety surveillance includes AMR surveillance • Active surveillance plan implemented • Participation in WHO GLASS yearly THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 39 Establish an antimicrobial • Antimicrobial use data • Reduction in AMU in humans use (AMU) monitoring collected for humans and • Reduction in AMU in animals system for human health, updated annually animal health and crops • Reduction in AMU in crops • Antimicrobial use data collected for animals and updated annually • AMU data collected for crops and updated annually Analyze and report out • EML and STGs updated • % compliance to STG’s in hospitals surveillance data to regularly against AMR data in • % compliance to STG’s in primary support clinical and policy animals health care decision making in all • EML and STGs updated sectors • % compliance to STG’s in animals regularly against AMR data in health humans 3. IPC and biosecurity Strengthen the existing • Updated biosecurity • Food safety testing—% of food biosecurity measures guidelines for each relevant contaminants (all bacteria, on hatcheries, farms, animal species and farming AMR bacteria and antimicrobial slaughter houses and food system residues) detected processing establishments • % of animal keepers and • % compliance of animal keepers to prevent, reduce and farmers trained in good and farmers with good animal contain pathogens animal husbandry and husbandry and biosecurity to improve livestock biosecurity measures measures productivity, animal welfare, food security and food safety Improve movement • # of breaches of movement • % reduction of breach movement controls of animals and control measures control animal products and border control mechanisms to reduce trans-boundary animal disease Track and reduce the • Updated IPC guidelines • % reduction of incidence of health burden of health care care associated infections i.e. • % of facilities with necessary associated infections (HAIs) surgical sites, catheter associated PPE and IPC equipment through improving IPC urinary tract, central line blood practices in all health care • % compliance with hand stream, ventilator pneumonias facilities in Zimbabwe hygiene practices • Improvement in knowledge, attitudes and behaviours on IPC of health workers as determined by a KAP study/ survey Strengthen the vaccination • Increase the number of herds • Increased % vaccination coverage programs in animals covered with vaccinations. of under 1 years old —humans and humans to improve from the current of 89% prevention and control of • % of herds covered with vaccines disease and reduce AMU Reduce the transmission • % of population using • # of outbreaks of waterborne of infectious diseases in improved sanitation facilities diseases communities, healthcare • % reduction of prevalence/ cetners, veterinary facilities incidence of typhoidal and through effective water, non-typhoidal salmonellosis and sanitation and hygiene cholera by 5% annually practices and provision of appropriate facilities. THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 40 4. Rational Use Improve access to • Total number of licensed AM • Antimicrobial use of OTC antimicrobials by animal access points medications—kgs of antimicrobials keepers by increasing • # of licensed AM access access points for the points in rural areas sale and provision of antimicrobials Strengthen control of • % of planned inspections • Antimicrobial use of OTC antimicrobials and their use successfully conducted medications—kgs of antimicrobials in animal health by animal • Guidelines on veterinary keepers and veterinary pharmacovigilance in place para professionals without limiting acess • ADR reporting tools in plance Implement sustainable • % of hospitals with • % of compliance with antimicrobial supervision, audit and functioning Hospital prescription in hospitals feedback mechanisms Therapeutics Committee • Antimicrobial use in humans— in health facilities by • % compliance with STGs DDDs having functional hospital medicines therapeutic committees in hospitals to ensure appropriate antimicrobial use by prescribers Ensure that standard • Up to date EML and STG’s— • Presence of an up to date EML and treatment guidelines (STGs) not more than 5 years old STGs that are not >5 years old. and Essential Medicine LIst • Animal health EML • Presence of an up to date EML. (EML) reflect the current developed diseases and pathogens in humans Ensure adequate supplies • % availability of • Presence of antimicrobials that are of quality assured essential antimicrobials that are on on the EML at appropriate sites. AM at various levels of the EML human and animal health delivery systems. Control public access • # of illegal access points of • % reduction of illegal access points to antimicrobials at the antimicrobials of antimicrobials. point of the pharmacy and veterinary medicine general dealers Strengthen regulations to • % of acts requiring revision • # of acts that have been revised for ensure appropriate use of that have been revised for animal health antimicrobials in animals animal health 5. Investment, R&D Develop innovate modern • # of research projects • % of research projects that have diagnostics, vaccine and initiated caused policy change. alternative thearpy to • # of articles in peer-reviewed antimicrobials international journals THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021 41