Iraq Action Plan of Antimicrobial Resistance (2018-2022)

2022. The Plan can be updated in response to the emerging issues and/or as new evidence becomes available. A monitoring plan is being developed by the AMR team to identify indicators and set targets to monitor progress of the of the National AMR Strategy objectives regarding human and animal health. Improving the knowledge about health associated infection (HAI) in health institutions contributes to support and identify the need for infection prevention, improving the management of health practices, as well as enhancing biosecurity measures in veterinary 6 institutions, thereby reducing the development of antimicrobial resistance and limiting the spread of MDROs. Promoting the understanding of (One Health) concept in antibiotic stewardship for the different sectors ensures prudent and appropriate use of antimicrobials and rapid diagnostics by taking the appropriate measures to ensure consistent and sustained access to quality medicines and to strengthen procurement systems, supply chains and antibiotics storage facilities. There is a need for quality control of veterinary medicines as well as improving the scope of practice for veterinary paraprofessionals to control antimicrobials users and dealers by legislating the laws that regulate their handling. The plan acknowledges the need of researches to be carried out to understand the links for AMR development and spread among human, animal and environment to find alternative therapies through research activities carried by the ministry of higher education and scientific research in coordination with MOH and MOA. Implementers 1- Ministry of Health / Environment. 2- Ministry of Agriculture. Contributors 1- Ministry of Higher Education & Scientific Research. 2- Ministry of Municipalities and Public Works. 3- Ministry of Defense. 4- Ministry of Interior. 5- Popular Mobilization Forces. 6- The Ministry of Industry. 7- Pharmacists Syndicate. 8- Medical Syndicate. 9- Veterinaries Syndicate. 7 Introduction For decades, antimicrobial resistance (AMR) has been a constant and growing threat to a range of infections caused by bacteria (1,2). This threat is a major problem for individual and community health where pathogenic bacteria can be resistant to many antimicrobials. Besides the incorrect use of broad-spectrum antibiotics in clinical practice (3,4) . For example, increased urinary tract infection (UTI), caused by bacteria resistant to modern-day antibiotics and difficult to control, as well as the economic cost burden of medical services (5,6) . Recent studies have shown that a number of important factors include lack of medical and health awareness, lack of surveillance programs, lack of antibiotic stewardship in health institutions serving the community, lack of infection prevention & control policy, limited detection of new antibiotics, lack of global surveillance , The lack of rapid clinical diagnosis of infectious diseases has played a major role in promoting the emergence and spread of drug resistance(7) Patients with antimicrobial resistance are more likely to stay longer in hospitals for poor progress in treatment(6). In September 2017, the Iraqi government evaluated and analyzed the reality of antimicrobial resistance and in collaboration with an external team of experts for EMRO and using evaluation tools for the WHO. In Iraq, there were indicators of misuse of antimicrobials by health care providers and poor control programs resulting in the rapid spread of resistant microbes and to control antimicrobial resistance, there is a need for a common approach and well integrated and coordinated efforts at the global, regional & national levels. This requires a comprehensive response strategy to be developed on the basis of mutual cooperation between stakeholders and decision-makers. An analysis of strengths, weaknesses, opportunities and threats (SWOTs) was performed to achieve a clear strategy for the development of a national action plan and priority gaps were identified as:

1. Poor public awareness and weak coordination of AMR awareness activities by the government and partners.

2. No ‘One Health’ approach of animal and human national disease surveillance systems, non-existence of a national AMR laboratory surveillance system and no dedicated funding for AMR surveillance activities.

3. Inactive and old guidelines of Infection Prevention and Control (IPC) program as well as poor budgetary support for its activities in health facilities

4. Lack of antimicrobial stewardship in both private and public health sectors. Our goal is to prevent, slow down, and contain the spread of AMR through the continuous availability of safe, effective, and quality-assured antimicrobials and sets out a comprehensive roadmap to deal with AMR in Iraq. 8 Governance In April 2017, the Iraqi Ministry of Health approved the establishment of AMR National Coordinating Committee (AMR-NCC) comprising policy makers from human health, animal health and environment sectors in addition to the private sector. Its role is to determine the outline of the national action plan to contain AMR as a society issue to create a healthy nation with adequate access to quality medical services and effective medicines aimed at preventing the emergence and spread of AMR among the Iraqi people. Figure 1. Communication channels for multisectors coordination For the purpose of follow-up and teamwork among the ministries implementing the national action plan, AMR units were established in each of the ministries of health and agriculture involving the specialties concerned with implementing and following up the national action plan items and to communicate with the AMR-NCC which is in charge of implementing the AMR national action plan and also works on drafting guidelines and policies to ensure a comprehensive approach involving all levels of the government, as well as monitoring the progression and participating in developing the annual progress report. 9 AMR Unit and in coordination with the WHO organised and was engaged in two consultation workshops with a group of specialists under ‘one health’ approach and sought input to address the five strategic objectives and associated activities, as well as implementing point prevalence survey as Iraq is the first country in the middle east to adapt this action . This is considered a very important step to establish baseline for HAI, prescribing and using antimicrobials, as well as the microbiological description for the causes of infection. Preliminary data focuses on establishing future goals to straighten the national monitoring system. Implementing the national strategy requires a national program of action through the analysis and evaluation of the current situation, together with the strategic and operational plan to enable both AMR units to make the most progress towards implementation of the NAP by monitoring and evaluation, to achieve the five global objectives (Figure 2). Figure 2: An explanatory structure for the national strategy 10 The Iraqi Strategic Plan for Combating AMR National strategy is focus on promoting awareness and education of the AMR phenomenon among the public, health care workers and veterinarians who represent the backbone stone of the plan, proactive control of the resistant bacteria, straightening infection prevention and control, introducing health care associated infection monitoring system, and applying regulations that control the use of antibiotics in both the human and animal health sectors and the proactive monitoring of drug resistance, as well as the good management of antimicrobials, infection prevention and control program in hospitals, veterinary institutions and poultry fields with encouraging researches are solutions that can significantly reduce the antimicrobial resistance as shown in figure (3). Figure 3: Iraqi National Action frame work for combating AMR 11 Improve awareness and understanding of Antimicrobial Resistance through effective communication, education and training Steps need to be taken urgently in order to raise awareness of AMR and Objective this is to be done through promotion of behavioral changes by supporting public communication programs that target different sectors One (human and animal health). In one aspect, raising awareness of AMR in school curricula will promote better understanding and awareness from an early age, and on the other side using “one health” concept to combat AMR as core component of professional education, training, continuing education and development in both human and animal health. So, to cover different society groups starting with general population and going through health professionals. The improvement that we seek in national awareness and knowledge of AMR will be established through an evidence-based public communication health program that targets community, health and veterinary care providers. The priority actions in this strategic objective are as follows:  Increase national awareness and behavioural change of the general public and professionals in both human and animal health on AMR.  Encouraging sustained behaviour change for infection control, biosecurity measures and for antibiotics stewardship programmes.  Increase community awareness on hygiene and vaccination.  Advocating for developing and enforcing plan to combat AMR.  Improve knowledge of AMR and related topics. NAP Objective (1): Increase National awareness and behavioral change of the general public and professionals in both human and animal health on antimicrobial resistance. Strategic interventions Activities 1.1.1: Develop strategy change behavior and increase awareness. 1. 1: Design and implement  Conducting AMR situational analysis that supports programmes to raise awareness awareness and behavior change programming. and change behaviour  Identify suitable target audiences  Identify appropriate tools and channels  Implementing mass communication awareness campaigns  Implementing community mobilization activities  Identifying a theory of behaviour change that fits the Iraqi context  Messaging and content drafting  Identify the needed human and financial resources  Setting a timeline for developing a strategy and implementing a set of activities to increase national awareness. 1.1.2 Training and capacity building of those who implement the strategy. 12 1.1.3 Monitoring and Evaluation of awareness and behavioural change activities. 1.2: Evidence base to 1.2.1: Conduct knowledge, Attitude and Practice (KAP) studies encourage better understanding on AMR in different social and professional groups. of antibiotic use and AMR. 1.2.2: Developing awareness programs that promote and support the optimal use of antibiotics in human and animal health. NAP Objective (2) Encouraging sustained behavior change for infection control, biosecurity measures and for antibiotics stewardship programmes Strategic interventions Activities 2.1: Insert behavior change 2.1.1: Raising awareness and behaviour change in all training within infection control and programmes of IPC, bio-security measures and antibiotics programs, biosecurity stewardship of both human and animal health. measures and antibiotic stewardship. NAP Objective (3): Increase community awareness on hygiene and vaccination Strategic interventions Activities 3.1: promote public awareness 3.1.1: Conduct awareness campaigns to promote the importance programs about hygiene and of hygiene and immunization activities (for human and animal immunization program health). 3.1.2: Integrating AMR related messages into hygiene and immunization program. NAP Objective (4) Advocating for developing and enforcing plan to combat AMR Strategic interventions Activities 4.1: Government project to 4.1.1: Prepare a comprehensive national policy initiative to adopt a policy addressing the address the phenomenon of antimicrobial resistance. phenomenon of AMR. 4.2: Develop a plan for sharing 4.2.1: Raise awareness of stakeholders about strategic contents and communicating with to take actions to reduce the impact of AMR. stakeholders to support 4.2.2: Customize a page of 'one health' concept on websites for community awareness and both MOH and MOA to ensure the access to reliable sources of participation in the information on antibiotics and AMR and to facilitate the implementation of the strategy. coordination of activities. 4.2.3: Add awareness week of antibiotics to the national calendar. 4.2.4: Multimedia awareness campaigns:  Cooperate with media departments of ministries to conduct awareness programs that demonstrate the optimal use of antibiotics and the risk of using them without consulting doctors and veterinarians.  Cooperate with syndicates and professional unions to engage the private sector in raising awareness of AMR and the way to control them.  Using social networking sites. 13 NAP Objective (5): Improve Knowledge of AMR and related topics Strategic interventions Activities 5.1: Embedding AMR as a 5.1.1: Review and update current curricula on human and core component of education. animal health. 5.1.2: Integrate hygiene, infection prevention control, and rational use of antibiotics into education and training program. 5.1.3: Take advantage of international and national events to highlight AMR 5.2: Promoting understanding 5.2.1: Training of school health coordinators and teachers on and awareness of the AMR AMR- related issues. phenomenon at early age. 5.2.2: Using visual aids and educational materials dealing with the causes of drug resistance to AMR and ways to avoid them among school children. 5.2.3: Implement extracurricular activities in schools by students and teachers regarding AMR. Strengthen the knowledge and evidence base through surveillance and research Objective Surveillance of AMR is very critical for providing data regarding the Two extent and trends of the AMR problem. In Iraq, there is no AMR surveillance in the context of one health approach, which in turn limits any national efforts to tackle AMR. So, the future goal is to establish a national surveillance system for microbes that have resistant strains, work on the training of laboratory personnel, support these personnel to conduct scientific researches and to make sure that the laboratories are adequately equipped with all the devices and related consumables in order to have reliable data that support the process of AMR surveillance. Moreover, a coordinated mechanism for AMR reporting will be established in order to share information within the one health approach. The national surveillance process also include the creation of the National Coordinating Center (NCC), which consolidates the national data and sends it electronically to the international (GLASS) website (these data are only sent after being confirmed by the Reference Laboratory (Central Public Health Laboratory), these data also include the identifying sites for antimicrobial surveillance (hospitals, health centers and veterinary health institutions) in which it was diagnosed. 14 The strategic interventions under surveillance and research include the following priority actions:  Establish a national surveillance system for AMR.  Build laboratory capacity to produce high quality data.  Identify research priorities. NAP Objective (6): Establish a national surveillance system for AMR Strategic interventions Activities 6.1: Establish antimicrobial 6.1.1: Establish NCC. surveillance system in human, 6.1.2: Place the Antimicrobial Susceptibility Testing foods, animals, and environment (AST) on KIMADIA priority list of MOH and import list of MOA. 6.1.3: Building an epidemiological database to identify the national priority microorganisms. 6.1.4: Generate a multi-sector AMR information sharing system in humans, animals and environment. 6.2: Identify and develop 6.2.1: Designate NRL a national reference 6.2.2: Assess the existing capacities according to the laboratory (NRL). international standards 6.2.3: Participate in laboratory quality assurance system (internal and external). 6.3: Designate AMR 6.3.1: Assess the existing laboratories’ capacity to carry out surveillance sites. AMR surveillance. 6.3.2: Conduct training, and supportive supervision for laboratory personnel on national surveillance of AMR. 6.4: Establish IT system for 6.4.1: Develop an e-mail system for bacterial surveillance communication. between all surveillance sites and NCC. 6.5: Participate in global 6.5.1: Identify focal points. surveillance system WHO- 6.5.2: Update and develop a priority list of antimicrobials and GLASS. antibiotics. 6.6: Establish antibiotics 6.6.1: Establish residues of antibiotics test in food. residual test. 6.6.2: Establish residues of antibiotics test in meat. NAP Objective (7) Build laboratory capacity to produce high quality data Strategic interventions Activities 7.1: Update current capabilities. 7.1.1: Conduct training for laboratory staff on standard diagnostic methods of AMR. 7.1.2: Unify and update the international standards (CLSI) that are used by all labs for interpretation the results of AST. 7.1.3: Update a master list of materials / reagents / items that are required for testing AMR and ensure continuous availability. 7.1.4: Strengthen quality control and assurance system for AMR surveillance. 15 7.1.5: Identify the types of resistant bacteria and the responsible gene using an advance technique of PCR. NAP Objective (8) Identify Research priorities Strategic interventions Activities 8.1: Establishment of AMR 8.1.1: Engage relevant stakeholders to identify current gaps in operational research plans. knowledge and potential research areas. 8.1.2: Establish a mechanism of sharing AMR research findings between universities, health and veterinary institutions. 8.1.3: Enrollment AMR within priority research list for postgraduate studies. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures. Objective Better hygiene and infection prevention measures are essential to reduce the infection and cutdown the emergence and spread of Three resistant bacteria in both human and animals. In addition, the effective measures of sewage treatment and processing also very important in reducing the spreading of infection. Proper training and education of health personnel about the Infection Prevention and Control (IPC) is required to combat AMR. On the aspect of community level there is a need to strengthen the national infection prevention and control programme with the use of vaccines. Overall practicing of IPC will generally lead to better health outcome in human and animal health, while overall treatment costs will be reduced. To address these challenges, three priorities have been identified:  Infection Prevention and Control in both humans and animals’ health.  Strengthen Health Waste Management system at all levels.  Promote community-based prevention through access to safe drinking water, sanitation and hygiene. 16 NAP Objective (9): Infection Prevention and Control in both human and animal health Strategic interventions Activities 9.1 : Promote a national 9.1.1: Conduct a national survey to assess the current program programme for IPC in all levels of infection control in health institutions. of human health care. 9.1.2: Develop the national IPC guidelines with implementation for infection prevention and control in all health care settings according to WHO assessment. 9.1.3: Establish and design IPC programme in all primary healthcare setting. 9.1.4: Restructure current infection control units in health institutions and promoting the role of the public health and epidemiology specials to participate in managing the unit. 9.1.5: Plan a national training for all IPC employee at all levels. 9.2: Establish a system of 9.2.1: Conduct HAI survey to identify a national baseline. healthcare associated infection 9.2.2: Prepare HAI plan. (HAI). 9.2.3: Identify a number of hospitals to implement (HAI). 9.2.4: Train IPC professionals on surveillance data collection. 9.3: Develop and design IPC 9.3.1: Prepare a specific structure of infection control at all programme in animals. veterinary institutions. 9.3.2: Produce IPC guidance according to OIE standard. 9.3.3: Training the technical staffs (especially employee of Epidemiological Departments in all provinces) on (IPC) programme and its implementation. 9.3.4: Apply cleaning and sterilization protocols in Abattoir. 9.4: Promote the use of vaccine 9.4.1: Expand immunization programme for the target animal for animals’ health species. NAP Objective (10): Strengthen Health Waste Management system at all levels. Strategic interventions Activities 10 .1: Improve and strengthen 10.1.1: Develop a management plan for medical wastes in all Health Waste Management healthcare facilities for both human and animal. systems in both human and 10.1.2: Develop a monitoring system for medical waste animal sectors. management and proper disposal of dead livestock . NAP Objective (11): Promote community-based prevention through access to safe drinking water, sanitation and hygiene Strategic interventions Activities 11.1: Improving access to safe 11.1.1: Assess access to safe drinking water and sanitation water for human consumption 11.1.2: Rehabilitation of drinking water stations projects. and sanitation. 11.1.3: Sewage treatment in veterinary institutions and Abattoir. 17 Optimize the use of antimicrobial medicines in human and animal health. The emergence of multidrug-resistant bacteria has led to continue Objective demand for new antibiotics which are always expensive and cannot be provided in many health institutions, this will lead to increased Four morbidity in society and in order to maintain the effectiveness of antibiotics and to postpone the spread of the bacterial resistant phenomenon to antibiotics, we are obligated to follow the scientific and rational use of antibiotics. This can be done through monitoring the use of antibiotics and keep an eye on the resistance of bacteria, and on the other aspect we can organize a regular feedback protocol with all doctors who are in charge of prescribing antibiotics. This can increase control of bacterial resistance and prevent infection at all levels of health care (primary, secondary and tertiary). The excessive use of antimicrobial agents in animals as growth promoter and non- compliance with safety period following the use of antibiotics ,in addition to the irrational use of antimicrobial agents in animals has a negative impact on human due to the occurrence of antibiotic residues in the food of animal origin such as meat, milk and egg. There is a need to develop antimicrobial control programs to address this problem and not only to reduce inappropriate use but also to improve antimicrobial selection, dosage, route, and duration of treatment to maximize clinical treatment or prevent infection, while minimizing unintended consequence. The following priorities have been identified:  Regulated access to high-quality antimicrobial agents.  Ensure optimal use of antimicrobial agents in both human and animal NAP objective (12): Regulated access to high-quality antimicrobial agents Strategic interventions Activities 12.1: Strengthen legislation to 12.1.1: Prevent dispensing of antimicrobials without regulate prescription and prescription and deliberation of antimicrobial as a growth dispensing of antimicrobials promoter by farmers and breeders of poultry and fish, with (human and animals) updating the Iraqi standard of feed free of growth promoters including antimicrobials and hormones. 12.1.2: Setting regulations regarding the use of antibiotics in the private sector for human health and non-therapeutic purposes in animal health. 12.1.3: Control the distribution of antibiotics by unauthorized medical practitioners. 12.1.4: a- Prevent the deliberation of unauthorized antimicrobials from the Ministries of Health and Agriculture in the private sector. b-Monitor the safety of new antimicrobials through pharmacovigilance activities 18 12.1.5: Issue instructions to ensure animal's meat and their products are free from antibiotics residue. 12.1.6: Regulate the optimal use of antibiotics in animal treatment. 12.2: Strengthen the supply chain 12.2.1: Place antibiotics agent on KIMADIA priority of antibiotics (selection, importing list. procurement, storage and 12.2.2: Study the organization of the supply mechanism for distribution) antimicrobials. 12.2.3: Strengthening the control system of importing of antibiotics of the veterinary side and its registration mechanisms. NAP objective (13): Ensure optimal use of antimicrobial agents in both human and animal Strategic interventions Activities 13.1: Establish a management 13.1.1: Formation of a Central Committee to administer committee of antibiotics in antibiotics with assignments and duties. human and animal health 13.1.2: Set up a plan to administer antibiotics for all levels of health care. 13.1.3: Setting up a survey to optimize the use of antibiotics. 13.1.4: Prepare guidelines of optimal use of antibiotics. 13.1.5: Choose hospitals to be ideal in implementing of antibiotics management. 13.1.6: Prepare a plan for the management of antibiotics in veterinary field. 13.1.7: Prepare guidelines of optimal use of antibiotics in veterinary field. 13.2: Introduce the concept of 13.2.1: Prepare surgical prevention guidelines. surgical prevention. 13.2.2: Training employees on applying of vocabulary of guidelines. 13.3: Building the capacity of 13.3.1: Prepare a training programme on the correct medical and veterinary description of antibiotics (hospitals and health centres and personnel on optimal use of veterinary institutions). antibiotics. 13.3.2: Training employee of medical and veterinary at all levels Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase Objective investment in new medicines, diagnostic tools, vaccines and other interventions Five A strong research and development agenda are needed to fill gaps that still exist in understanding of prevalence, patterns of AMR and to understand the epidemiological impact of AMR on human, animal and even the pathogens. A better understanding of these issues will create the base for ensuring the best to treat, prevent and contain them in the future. 19 New medicines, diagnostic technologies and vaccines are needed to limit emerging and spreading antimicrobial resistant pathogens. To estimate the burden of AMR on health, studies must be carried out to determine its clinical and economic impact on increasing morbidity and mortality in Iraq. This will be done by taking the following action:  Strategic research to determine priority, methodology and knowledge gaps in the field of AMR. NAP objective (14): Strategic research to determine priority, methodology and knowledge gaps in the field of AMR. Strategic interventions Activities 14.1: Identify research areas that 14.1.1: Forming a multi-sectoral committee from the relevant needed for implementation of ministries (Health, Agriculture, Higher Education and the comprehensive national plan Scientific Research, Industry) and private sector. of action to control AMR using 14.1.2: Urge universities to conduct research on AMR. "one health" approach. 14.1.3: Support research on alternatives of antibiotics. 14.2: Estimate the economic 14.2.1: Conduct a study to assess the impact of the economic impact of AMR. burden of antibiotics on human health. 14.2.2: Building an information base of antibiotics consumption and its economic burden. 14.3: Encourage the national 14.3.1: Conduct a study to measure the effectiveness of local pharmaceutical factories to production of antibiotics on resistance by national support the NAP. pharmaceutical factories. 20 Operational Plan NAP Objective (1): Increase National awareness and behavioral change of the general public and Professionals in both human and animal health on antimicrobial resistance. Source Responsible Cost Activity Unit Quantity Date of Indicator entity funding AMR Unit+ Media Fourth 23.594.000 1.1.1: Develop strategy change and Health External Strategy 1 Semester Strategic behavior and increase awareness Awareness funder 2018 Department AMR Unit+ Media and Health Number of Executed 6 2 per each MOH Courses Awareness 81.975.000 1.1.2: Training and capacity year (2019- Department building of those who implement Training 2020) + 1 the strategy per year MOA/ Directorate (2021-2022) of Agricultural Number of Executed 6 MOA 60 000 000 Courses Extension and Training One per 1.1.3: Monitoring of awareness 4 each year List of Supervisors and behavioral change activities (2019-2022) Monitoring & MOH +MOA Fourth Evaluation Evaluation of awareness and Semester of 2 Questions behavioral change activities 2020 and 2022 - 21 - Media and Health Fourth Awareness MOH + semester of Department + 21.000.000 Implementation of 2 External 2018 and Popular the study 1.2.1: Conduct knowledge, funder 2022 Mobilization Attitude and Practice (KAP) Study Forces studies on AMR in different Fourth social and professional groups. MOA/ Directorate Semester / 21 000 000 of Agricultural Implementation of 2 one each MOA Extension and the study year of 2019 Training and 2022 AMR Unit+ Media 1.2.2: Developing awareness and Health Implementation of MOH 40.974.000 programs that promote and Awareness course support the optimal use of Training 4 2019-2022 Department antibiotics in human and animal Implementation of health. MOA MOA 30 000 000 course NAP Objective (2): Encouraging sustained behavior change for infection control, biosecurity measures and for antibiotics stewardship programmes 2-1-1: Raising awareness and AMR Unit+ Media behavior change in all training and and Health programmes of IPC, bio-security Central Awareness implementation 4 2019-2022 MOH measures and antibiotics Meeting Department + of meeting stewardship of both human and Infection Control animal health Department - 22 - AMR Unit+ Media and Health implementation Awareness of meeting MOA Department + Infection Control Section NAP Objective (3): Increase community awareness on hygiene and vaccination AMR Unit+ Media and Health Awareness Department + Media External 270.000.000 Department + funder Immunization Section + Municipal Council 3-1-1: Conduct awareness campaigns to promote the Implementation importance of hygiene and Awareness 4 2019-2022 AMR Unit+ of campaign immunization activities (for human campaign and animal health) Directorate of Agricultural Extension and Training + Media External 60 000 000 Department + funder Epidemiology Department + Municipal Council - 23 - AMR Unit+ Media 1.000. and Health Awareness External 300.000.000 000 Department + funder Folder Immunization Section 3-1-2: Integrating AMR related s+ Number of Health messages into hygiene and 3500 2019-2022 printed out and messages immunization program Poster folders s+2 AMR Unit+ Spots Directorate of External 100 000 000 TV Agricultural Extension funder and Training + Media Department NAP Objective (4) Advocating for developing and enforcing plan to combat AMR 4-1-1: Prepare a comprehensive national policy initiative to address National 1st 1 AMR Unit MOH Legislation law the phenomenon of antimicrobial policy Semester/2018 resistance. AMR Unit+ Media and Implementation Health Awareness MOH 2.400.000 of a symposium 4-2-1: Raise awareness of Department Education stakeholders about strategic al 4 2019-2022 AMR Unit+ contents to take actions to reduce Seminars Directorate of the impact of AMR. 4 000 000 Implementation Agricultural Extension MOA of a symposium and Training + Media Department - 24 - AMR Unit+ Media and 4-2-2: Customize a page of 'one Health Awareness MOH health' concept on websites for Department + IT both Ministries of health and Section agriculture to ensure the access to Webpage 1 2019 Access Page reliable sources of information on AMR and to facilitate the coordination of activities. AMR Unit+ Directorate of Agricultural Extension MOA and Training + IT 1 000 000 Section Awareness Include Week awareness within the 1 2018-2022 MOH week within the National national events Schedule AMR Unit+ Media and Health Awareness National Department event to MOH 75.000.000 4-2-3: Add awareness week of Implementation celebrate 5 2018-2022 +Externa antibiotics to the national calendar of the event Awareness l funder Week National AMR Unit+ event to Directorate of 5 000 000 Implementation celebrate 5 2018-2022 MOA Agricultural Extension of the event Awareness and Training Week - 25 - Awareness AMR Unit+ Media and program in 5 2019-2022 Health Awareness MOH all Department Ministries Awareness materials AMR Unit+ (Medical on social Ongo 2019-2022 ،Dental ، Pharmacists) media ing Syndicates sites of 4-2-4: multimedia awareness syndicates campaigns: Awareness Conti materials nuous on social aware media ness MOA + Veterinary 4 000 000 2018-2019 sites of mater Medicine Syndicate syndicate ials + + semin Seminars ar social site 1 2018-2019 AMR Unit NAP Objective (5): Improve Knowledge of AMR and related topics Education 5-1-1: Review and update current al curricula on human and animal 1 2020-2022 AMR Unit+ MOHE Curriculu health m - 26 - 5-1-2: Integrate hygiene, infection Education prevention control, and rational al 1 2020-2022 AMR Unit+ MOHE use of antibiotics into education Curriculu and training program. m AMR Unit + School 5-1-3: Take advantage of Education Health Sector + Media Ongoi Number of international and national events al 2019-2022 and Health Awareness MOH ng seminars to highlight AMR. Seminars Department + MOE 5-2-1: Training of school health Number of AMR Unit+ School coordinators and teachers on Training 4 2019-2022 MOH Executed Health Sector + MOE AMR- related issues. Courses One 5-2-2: Using Visual aids and Visual Teach AMR Unit+ Media and Number of educational materials dealing with aids and ing Health Awareness 2019-2022 MOH 55.000.000 Educational the causes of AMR and ways to educationa Mater Department+ School Materials avoid them among schoolchildren. l materials ial per Health Sector + MOE year 20 5-2-3: Implement extracurricular school MOH/School Health activities in schools by students Activity 2019-2022 per Sector + MOE and teachers regarding AMR. year NAP Objective (6): Establish a national surveillance system for antimicrobial resistance 6-1-1: Establish a National Ministerial NCC 1 2018 AMR Unit MOH Coordinating centre (NCC) Approvals 6-1-2: Place the antibiotic Availability of AMR Unit+ KIMADIA MOH sensitivity test (AST) on AST 1 2018 test KIMADIA priority list Import list MOA - 27 - 6.1.3: Building an 2nd Semester MOH + Number of epidemiological database to /2018 and PPS 3 AMR Unit External surveys carried identify the national priority 2020 and funder out microorganisms 2022 6-1-4: Generate a multi-sector AMR information sharing system Electronic MOH + Application 1 2020 AMR Unit 600 000 000 in humans, animals and System MOA system environment Reference 6-2-1: Designate an NRL 1 2018 AMR Unit MOH Y/N Lab 6-2-2: Assess the existing Evaluation Evaluation capacities according to and follow- 1 2018 AMR Unit MOH form international standards up 6-2-3: Participate in laboratory MOH + Evaluation Number of quality assurance system (internal 1 2019 MOH External Report Reports and external) funder 6-3-1: Assess the existing Evaluation laboratories’ capacity and appoint Evaluation and follow- 23 2018-2022 MOH MOH laboratories to carry out AMR form up surveillance. MOH + 6-3-2: Conduct training, and AMR Unit + CPHL External 34.634.000 supportive supervision for Number of Training 5 2018-2022 funder laboratory personnel on national courses 50 000 000 surveillance of AMR AMR Unit MOA 6-4-1: Develop an e-mail system for bacterial surveillance between Email 1 2019 AMR Unit Y/N all surveillance sites and NCC 6-5-1: Identify focal points. Official Focal Point 2 2018 AMR Unit approval - 28 - 6-5-2: Update and develop a Develop a priority list of antimicrobials and Meetings 4 2019-2022 AMR Unit+ MOA MOH 80.000 priority list antibiotics. AMR Unit MOH 80.000 6-6-1: Establish residues of Meetings 4 2019-2022 Priority list antibiotics test in food. MOA MOA 500 000 6-6-2: Establish residues of Issuing Instructions 1 2019 MOA antibiotics test in meat. instructions NAP Objective (7): Build laboratory capacity to produce high quality data CPHL MOH 34.634.000 7-1-1: Conduct training for Number of laboratory staff on standard Training 4 2019-2022 Executed Department of veterinary diagnostic methods of AMR Courses laboratories and MOA 50 000 000 researches 7-1-2: Unify and update the MOH + international standards (CLSI) 2.000.000 List 5 2018-2022 AMR Unit + CPHL External Updated list that are used by all labs for funder interpretation the results of (AST). 7-1-3: Update a master list of CPHL MOH List of materials / reagents / items that estimates 4 2019-2022 Supply ratio are required for testing AMR and needed Veterinary lab. MOA 300 000 000 ensure continuous availability - 29 - 7-1-4: Strengthen quality control CPHL+ Laboratory Number of and assurance system for AMR Feedback Ongoing 2018-2022 Department / Directorate Reports surveillance of Technical Affairs 7-1-5: Identify the types of CPHL + MOH + resistant bacteria and the External PCR 1 2019 PCR available responsible gene using an advance Department of veterinary funder + technique of PCR. laboratories and MOA 240 000 000 researches NAP Objective (8): Identify Research priorities 8-1-1: Engage relevant stakeholders to identify current Number of Meetings 4 2019-2022 AMR Unit + CPHL MOH gaps in knowledge and potential Meetings research areas 8.1.2: Establish a mechanism of sharing AMR research findings Electronic 1 2020 MOH + MOHE + MOA Y/N between universities, health and system veterinary institutions 8.1.3: Put AMR on priority Priority research list for postgraduate 5 2018-2022 MOH + MOHE Y/N list studies. NAP Objective (9): Infection Prevention and Control in both human and animal health 9-1-1: Conduct a national survey MOH + to assess the current program of AMR Unit+ IPC survey 1 2019 External 46.529.000 Implementation infection control in health Section funder institutions. - 30 - 9-1-2: Develop the national IPC guidelines with implementation for infection prevention and Guidelines 1 2018-2019 IPC Section MOH Updated Copy control in all health care settings according to WHO assessment 9.1.3: Establish and design IPC Number of Directorate of Public programme in all primary IPC Unit 1200 2018-2022 MOH establishing Health healthcare setting. units 9-1-4: Restructure current infection control units in health institutions and promoting the AMR Unit+ IPC Updated Structure 1 2019 role of the public health and Section structure epidemiology specials to participate in managing the unit. 9-1-5: Plan a national training for Training 4 2019-2022 IPC Section MOH Y/N all IPC employee at all levels. Program One per each MOH + 9-2-1: Conduct HAI survey to Survey of AMR Unit+ IPC 57.020.000 2 year of 2018 and External Implementation identify a national baseline PPS Section 2020 funder 9-2-2: Prepare HAI plan MOH + 20.038.000 Preparing a Workshop 1 2019 AMR Unit External booklet funder Number of 9-2-3: Identify a number of AMR Unit+ IPC hospitals Hospital 23 2020-2022 MOH hospitals to implement (HAI). Section applying the system 9-2-4: Train IPC professionals on MOH + Number of surveillance data collection. Training 3 2020-2022 AMR Unit External 40.974.000 Executed funder Courses - 31 - 9-3-1: Prepare a specific structure Set up the of infection control at all Structure 1 2019 MOA MOA structure veterinary institutions. 9-3-2: Produce IPC guidance 30 000 000 Issuing Guidelines 1 2020 MOA MOA according to OIE standard. guidance 9-3-3: Training the technical staffs (especially employee of Number of Epidemiological Departments in Training 2 2019 MOA MOA Executed all provinces) on (IPC) Courses programme and its 10 000 000 implementation. Number of 9-3-4: Apply cleaning and Training 8 2019-2022 MOA MOA 30 000 000 Executed sterilization protocols in Abattoir. Courses Number of 9-4-1: Expand immunization Vaccination 72 000 000 8 2019-2022 MOA MOA implemented programme for the target species. campaigns 000 campaigns NAP Objective (10): Strengthen the Health Waste Management system at all levels MOH/ IPC Section + 10-1-1: Develop a management plan Environment Sector for medical wastes in all healthcare Plan 1 2019 MOH Y/N + Veterinary facilities for both human and animal Directorate 10-1-2: Develop a monitoring MOH + system for medical waste Environment Applying System 1 2020 management and proper disposal of Sector+ Municipality system dead livestock. of Baghdad + MOA - 32 - NAP Objective (11): Promote community-based prevention through access to safe drinking water, sanitation and hygiene 15 UNICEF + Ministry 11-1-1: Assess access to safe Evaluat Rate of Governora 2018 of Municipalities UNICEF drinking water and sanitation ion Completion tes and Public Works UNICEF + Ministry 11-1-2: Building the capacity of Rate of Project 1 2020 of Municipalities UNICEF workers in sanitation plants. Completion and Public Works Treatm 11-1-3: Sewage treatment in MOA + Rate of ent 6 2020-2022 MOA veterinary institutions and Abattoir. Environment Sector Completion Unit NAP objective (12): Regulated access to high-quality antimicrobial agents 12-1-1: Prevent dispensing of antimicrobials without prescription MOH Y/N and deliberation of antimicrobial as a growth promoter by farmers and Instruct Ongoing 2019-2022 breeders of poultry and fish, with ions updating the Iraqi standard of feed free of growth promoter including MOA Y/N antimicrobials and hormones 12-1-2: Setting regulations regarding MOH the use of antibiotics in the private sector for human health and non- Law 1 2020 Y/N therapeutic purposes in animal health. MOA - 33 - 12-1-3: Control the distribution of Inspecti antibiotics by unauthorized medical on MOH/ Inspector Rate of 16 2019-2022 practitioners. campai General Office Completion gns a- Inspecti 12-1-4: a- Prevent the deliberation of on unauthorized antimicrobials from the campai MOH / Inspector Ministries of Health and Agriculture General Office+ gns in the private sector. Pharmacovigilance Number of b- Ongoing 2019-2022 Department+ forms b-Monitor the safety of new Notific Pharmacists antimicrobials through ation Syndicate pharmacovigilance activities forms and Reports 12-1-5: Issue instructions to ensure Instruct Execute animal's meat and their products are Ongoing 2019-2022 MOA ions instructions free from antibiotics residue. 12-1-6: Regulate the optimal use of Instruct Execute Ongoing 2019-2022 MOA antibiotics in animal treatment. ions instructions Official 12-2-1: Place antibiotics agent on Implementatio Approv 1 2019 MOH KIMADIA priority importing list. n als Formin 12-2-2: Study the organization of the MOH/ Needs MOH ga Recommendati supply mechanism for 1 2019 Assessment +Externa commit ons list antimicrobials. Department l funder tee 12-2-3: Strengthening the control system of importing of antibiotics of Instruct Execute Ongoing 2019-2022 MOA the veterinary side and its ions instructions registration mechanisms. - 34 - NAP Objective (13): Ensure optimal use of antimicrobial agents in both human and animal 13-1-1: Formation of a Central Committee to Central Recommendati 1 2018 MOH administer antibiotics with Committee ons assignments and duties. 13-1-2: Set up a plan to AMR Unit+ MOH + 196.000 Preparing the administer antibiotics for all Workshop 1 2019 Directorate of External plan levels of health care. Technical Affairs funder 13-1-3: Setting up a survey to AMR Unit+ MOH + Implementatio optimize the use of Survey 1 2020 Directorate of External 46.529.000 n antibiotics. Technical Affairs funder AMR Unit+ MOH + 13-1-4: Prepare guidelines of Issuing Guidelines 1 2019 Directorate of External 17.077.650 optimal use of antibiotics. guidance Technical Affairs funder Number of 13-1-5: Choose hospitals to AMR Unit+ hospitals be ideal in implementing of Hospital 12 2019-2022 Directorate of applying the antibiotics management. Technical Affairs system 13-1-6: Prepare a plan for the Preparing the management of antibiotics in Workshop 1 2019 MOA MOA 10 000 000 plan veterinary field. 13-1-7: Prepare guidelines of Issuing optimal use of antibiotics in Guidelines 1 2020 MOA MOA 60 000 000 guidance veterinary field. AMR Unit+ MOH + 13-2-1: Prepare surgical Issuing Guidelines 1 2020 Directorate of External 5.692.550 prevention guidelines. guidance Technical Affairs funder 13-2-2: Training employees on applying of vocabulary of AMR Unit+ MOH + 40.974.000 Number of guidelines. Training 3 2020-2022 Directorate of External Executed Technical Affairs funder Courses - 35 - MOH + Central 13-3-1: Prepare a training MOH + Antibiotic 330.000 programme on the correct External Management Training description of antibiotics Workshop 1Central 2020 funder Committee Program (hospitals and health centres 60 000 000 and veterinary institutions). MOA MOA Ministry of Health / Public Health Directorate / Health MOH 13.658.000 Centers Department +Externa 13-3-2: Training employee of 1 Central + Directorate of Number of l funder medical and veterinary at all Training + 19 2020 Technical Affairs / Executed levels Terminals Patient Safety Courses Department MOA MOA 60 000 000 NAP objective (14): Strategic research to determine priority, methodology and knowledge gaps in the field of antimicrobial Resistance (AMR). 14-1-1: Forming a multi- sectoral committee from the relevant ministries (Health, Meeting's Agriculture, Higher Committee 1 2019 MOHE Recommendati Education and Scientific ons Research, Industry) and private sector. 14-1-2: Urge universities to Number of College or conduct research on Ongoing 2018-2022 MOHE published university antimicrobial AMR Research - 36 - 3 20.000.000 Number of 14-1-3: Support research on Research MOHE + MOH + MOH 2018-2020 published alternatives of antibiotics. center MOA MOA 80 000 000 Research 8 14-2-1: Conduct a study to MOH + assess the impact of the MOH / Economic Study 1 2020 External Y/N economic burden of Planning Section funder antibiotics on human health. 14-2-2: Building an information base of MOH / Economic Data 1 2021 Y/N antibiotics consumption and Planning Section its economic burden 14-3-1: Conduct a study to measure the effectiveness of Samarra Drug Rate of local production of antibiotics Study 2 2018-2020 Factory + ACAI Completion on resistance by national pharmaceutical factories - 37 - Monitoring and Evaluation Value Frequency Type and Planning element Indicator (calculat of data Data source Method Baseline purpose ion) collection 60% of population have knowledge about AMR NAP Objective (1) Increase 40% of National awareness and population have AMR Unit+ Media and behavioral change of the knowledge Outcome % Twice Health Awareness Questionnaire Baseline general public and professionals about the use of Department+ MOA in both human and animal antibiotics health on AMR. 70% of health professionals are aware of the best practices related to AMR 100% Design of awareness and AMR Unit+ Media and behavior change Every 3 Health Awareness Report Baseline programs years Department 1.1: Design and implement planned for programmes to raise awareness 2019 Output % and change behavior 25% Implementation AMR Unit+ Media and Field visits + of behavior Annually Health Awareness Baseline campaigns change Department programs - 38 - 1.1.2: Training and capacity AMR Unit + Media and building of those who implement 25% employees Input % Annually Health Awareness Training Baseline the strategy Department 1.2: Evidence base to encourage number of Every 2 better understanding of antibiotic implemented Output Number AMR Unit Report Baseline years use and AMR. activities 1.2.1: Conduct KAP studies on AMR Unit + Media and 2 studies 2 During 3 AMR in different social and Input Number Health Awareness Survey Baseline conducted Years professional groups. Department NAP Objective (2) Encouraging 50% of targeted sustained behavior change for employees have IPC unit+ Antibiotic Evaluation infection control, biosecurity improved Outcome % Annually Management Baseline forms measures and for antibiotics measures related Committee stewardship programmes to AMR 2.1: Insert behavior change within Number of infection control programs, hospitals Output Number Annually AMR Unit Report Baseline biosecurity measures and integrating antibiotic stewardship programme 2.1.1: Raising awareness and behavior change in all training and programmes of IPC, bio- Directorate of security measures and antibiotics Number of Training Not Input Number Annually Technical Affairs/IPC stewardship of both human and trainees programme available section animal health - 39 - 60% Improving community NAP Objective (3): Increase awareness of AMR Unit + Media and 2 During 3 community awareness on hygiene + Outcome % Health Awareness Report Baseline Years hygiene and vaccination increase Department vaccination coverage Number of 3.1: Promote public awareness activities and programs about hygiene and Output Number Annually Report Baseline initiative immunization program AMR Unit + Media and implemented Health Awareness 3.1.1: Conduct awareness Department +WHO + campaigns to promote the Number of MOA importance of hygiene and campaigns Input Number Annually Report Baseline immunization activities (for conducted human and animal health) Number of new NAP Objective (4) Advocating policies and General Secretariat of During 3 National policy Not for developing and enforcing legislations Outcome Number the Council of Years initiative available plan to combat AMR adopted by the Ministers + MOH government 4.1: Government project to adopt Twice a Policy option Not a policy addressing the Meetings Output Number AMR Unit year form available phenomenon of AMR 4.1.1: Prepare a comprehensive national policy initiative to General Secretariat of National Policy address the phenomenon of Percentage of During 3 Not Input % the Council of Initiative antimicrobial resistance. completion Years available Ministers + MOH evaluation Form - 40 - 4.2: Develop a plan for sharing and communicating with stakeholders to support During 3 Meetings Output Number AMR unit Report Base line community awareness and Years participation in the implementation of the strategy. 4.2.1:Raise awareness of stakeholders about strategic contents to take actions to reduce Seminars Input Number 1 every year AMR unit Report Base line the impact of AMR. Number of (universities, NAP Objective (5): Improve institutes and During 3 Not Knowledge of AMR and related schools) that Outcome Number MOHE+MOE Report Years available topics adopt the curriculum of AMR 5.1: Embedded AMR as a core AMR integrated During 3 Not Output Y/N MOHE+MOE Report component of education within curricula Years available 5.1.1: Review and update current Review and During 3 Not curricula on human and animal update Input Y/N MOHE+MOE Report Years available health. implemented 5.2: Promoting understanding and Lectures & AMR unit+ School awareness of the AMR Events Output Number 4 every year Awareness Base line Health Sector +MOE phenomenon at early age. material 5.2.2:Using Visual aids and AMR unit+ School educational materials dealing with Awareness Health Sector +MOE+ the causes of drug resistance to Input Number Ongoing Visual aids Base line material Media and Health AMR and ways to avoid them Awareness Department among school children. - 41 - NAP Objective (6): Establish a Participate in Not national surveillance system for Outcome Y/N Ongoing AMR unit Report GLASS available AMR 6.1: Establish antimicrobial Multi-sector Not surveillance system in human, Output Number Ongoing AMR unit Report data collection available foods, animals, and environment 6.1.3: Building an epidemiological database to AMR Unit+ CPHL+ Not Data sharing Input Number Ongoing Report identify the national priority MOA available microorganisms 6.2: Identify and develop a National national reference laboratory reference lab Output Y/N Once MOH Reports CPHL (NRL) designated Laboratory 6.2.2: Assess the existing External fulfills the capacities according to Input Y/N Ongoing MOH assessment Baseline elements of ISO international standards report system Al Kindi Teaching Hospital + Teaching 6.3: Designate AMR surveillance Number of laborator sites surveillance Output Number Annually MOH Report ies+ sites Imam Al Kadhimi n Teaching Hospital - 42 - 6.3.1: Assess the existing laboratories’ capacity and appoint % of planned Evaluation Not laboratories to carry out AMR sites assessed Input % Annually MOH forms available surveillance. % of sites 6.4: Establish IT system for sharing Not Output % Ongoing MOH Data & Reports communication electronic available information 6.4.1: Develop an e-mail system Official Not for bacterial surveillance between Contact E-mail Input Number Once MOH+MOA approval available all surveillance sites and NCC 6.5: Participate in global Number of sites Not surveillance system WHO- participate in the Output Number Ongoing MOH/NCC Data & Reports available GLASS system

1.Dr_Hu ssain Ali Official 6.5.1: Identify focal points. Input Y/N Once AMR Unit Report 2.Dr_Ra approval na A. Mahdi 50% of the abattoirs 6.6: Establish antibiotics residual During 3 applying Output % MOA Data Baseline test. Years antibiotic residues test 6.6.1: Establish residues of antibiotics test in food. Applying antibiotic Input Y/N Annually MOH+MOA Meetings Baseline residues test - 43 - % of surveillance data NAP Objective (7) Build applies to Not laboratory capacity to produce Outcome % Ongoing MOH+MOA Data international available high quality data quality standards Number of labs applying the Evaluation Not 7.1: Update current capabilities Output Number Ongoing MOH international reports available standards % of labs 7.1.4: Strengthen quality control participated in Evaluation Not and assurance system for AMR external quality Input % Ongoing MOH reports available surveillance assurance system Publications NAP Objective (8) Identify Number of Not Outcome Number Ongoing Scientific journals published from Research priorities published papers available Iraq Research agenda 8.1: Establishment of AMR to include AMR Not Output Number Ongoing MOH+MOA+MOHE Report by NCC operational research plans. operational available research 8.1.2: Establish a mechanism of Number of sharing AMR research findings Not AMR researches Input Number Ongoing MOH+MOA+MOHE Report by NCC between universities, health and available shared veterinary institutions Develop a NAP Objective (9): Infection functioning Program Evaluation Prevention and Control in Infection control Outcome Y/N Once according to WHO Assessment Baseline both human and animal program (IPCAT) tools health (according to WHO standard) - 44 - 50% of hospitals Directorate of apply IPC Evaluation Technical Affairs/IPC according to the forms 9.1: Promote a national section global standards During 3 programme for IPC in all levels of Output % Baseline 50% of health Years human health care Public Health care facilities Directorate / Health Report establish IPC Centers Department programme 9.1.2: Develop the national IPC guidelines with implementation Directorate of IPC for infection prevention and 100% updated Input % Once Technical Affairs/IPC Meetings Guidelin control in all health care settings section e according to WHO assessment. 9.2: Establish a system of Official Not healthcare associated infection System exist Output Y/N Once AMR unit approval available (HAI) % of 9.2.4: Train IPC professionals on surveillance Field visits + Not Input % On going MOH surveillance data collection sites that submit Reports available timely reports Establish of an 9.3: Develop and design IPC IPC program in Official Not Output Y/N Once MOA programme in animals. veterinary approval available institutions 9.3.2: Produce IPC guidance Workshop+ Guidelines Input Number Once MOA Baseline according to OIE standard. Meetings Number of 9.4: Promote the use of vaccine campaigns Output Number Annually MOA Report Baseline for animals health implemented 9.4.1: Expand immunization programme for target animal Coverage rate Input % Annually MOA Report Exist species coverage. - 45 - NAP Objective (10): Strengthen Percentage of health-care Health Waste Management institutions Medical Waste Health care institutions system at all levels. Outcome % Ongoing Assessment Update disposing of in MOH Form medical waste safely 25% Percentage 10 .1: Improve and strengthen of institutions Institutions applying the health waste management systems Output % annually Reports Exist applying the system in both human and animal sectors system 10.1.1: Develop a management plan for medical wastes in all management Directorate of Input Y/N Once Revision plan Exist healthcare facilities for both plan Technical Affairs human and animal Percentage of NAP Objective (11): Promote population using community based prevention Every 4 safety drinking- Outcome % UNICEF survey Report 86.8 through access to safe drinking Years water and water, sanitation and hygiene sanitation Percentage of 11.1: Improving access to safe population Every 4 water for human consumption and Output % UNICEF survey Report 38.4 served by Years sanitation. sewage network 11.1.2: Rehabilitation of drinking Eligible Every 4 Input Number UNICEF survey Report 191 water stations projects. projects Years NAP Objective (12): Number of Optimize the Use of instructions and Outcome Number Ongoing MOH+MOA Report Baseline Antimicrobial Medicines legislation - 46 - 12.1: Strengthen legislation to regulate prescription and Implemented Output Y/N Ongoing MOH+MOA Report Baseline dispensing of antimicrobials legislations (human and animals) 12.1.2: Prevent dispensing of antimicrobials without prescription and circulation of antimicrobial as a growth 25% of promoter by farmers and breeders During 4 Not implementation Input % MOH+MOA Report of poultry and fish, with updating Years available per year the Iraqi standard of feed free of growth Promoter including antimicrobials and hormones 12.2: Strengthen the supply chain 100% import of antibiotics (selection, During 4 priority list for Output % MOH+MOA Report Baseline procurement, storage and Years antimicrobial distribution) 12.2.1: Place antibiotics agent on 100% Official Not Input % Once MOH Report KIMADIA priority importing list. approval available NAP objective (13): Ensure optimal use of antimicrobial 50% During 3 agents in both human and implementing Outcome % MOH+MOA Report Baseline Years animal optimal use 13.1: Establish a management 50% human and committee of antibiotics in human animal health and animal health During 2 institutions that Output % MOH+MOA Report Baseline Years apply (antibiotic steward ship) - 47 - 13.1.1: Formation of a Central Committee to administer 100% Official Input % 2018 MOH Exist antibiotics with assignments and Committee exist approval duties. % of health care institutions 13.2: Introduce the concept of applied the During 4 Output % MOH Report Baseline surgical prevention concept of Years surgical prevention 13.2.1: Prepare surgical 50% Rate of Not Input % 2019 MOH Meetings prevention guidelines. Completion available 50% of health care institutions During 2 13.3: Building the capacity of applying Output % MOH+MOA Training courses Baseline Years medical and veterinary personnel appropriate use on optimal use of antibiotics. of antibiotics. 25% of medical 13.3.2: Training employee of and veterinary Input % One year MOH+MOA Training courses Baseline medical and veterinary at all staff trained levels NAP objective (14): Strategic Number of research to determine priority, During 4 Availabl completed Outcome Number MOHE Research methodology and knowledge Years e researches gaps in the field of AMR. 14.1: Identify research areas that needed for implementation of the Recommendatio Not comprehensive national plan of Research agenda Output Number Once MOHE ns available action to control AMR using "one health" approach - 48 - 14.1.1: Forming a multi-sectoral committee from the relevant ministries (Health, Agriculture, Not Committee exist Input Y/N Once MOHE Reports Higher Education and Scientific available Research, Industry) and private sector. Number of 14.2: Estimate the economic MOH\Planning Not studies Output Number Ongoing Reports impact of AMR Directorate available conducted 14.2.1: Conduct a study to assess the impact of the economic percentage of During 2 MOH\Planning Research Not Input % burden of antibiotics on human Completion Years Directorate Evaluation Form available health. 14.3: Encourage the national Samarra Drug Official pharmaceutical factories to Output Number Ongoing MOH Baseline Factory + ACAI approval support the NAP 14.3.1: Conduct a study to measure the effectiveness of local percentage of During 2 Research Not production of antibiotics on Input % Drug factory Completion Years Evaluation Form available resistance by national pharmaceutical factories - 49 - References:

1. Bush, K. "Improving known classes of antibiotics: an optimistic approach for the future." Current opinion in pharmacology 12.5,2012: 527-534.

2. Laxminarayan R, et al. "Antibiotic resistance—the need for global solutions." The Lancet infectious diseases 13.12 .2013: 1057-1098.

3. ZowawI H., Hosam M., et al. The emerging threat of multidrug-resistant Gram- negative bacteria in urology. Nature Reviews Urology, 2015, 12.10: 570.

4.Meier, Silvan, et al. "Extended-spectrum β-lactamase-producing Gram-negative pathogens in community-acquired urinary tract infections: an increasing challenge for antimicrobial therapy." Infection 39.4 (2011): 333-340.-340.

5. Liu, Yi-Yun, et al. Emergence of plasmid-mediated colistin resistance mechanism MCR-1 in animals and human beings in China: a microbiological and molecular biological study. The Lancet infectious diseases, 2016, 16.2: 161-168.

6. Zowawi, Hosam M., et al. "Stepwise evolution of pandrug-resistance in Klebsiella pneumoniae." Scientific reports 5 2015: 15082.

7. Marie K., Jean-Marc R. Emergence of resistance to carbapenems in Acinetobacter baumannii in Europe: clinical impact and therapeutic options. International journal of antimicrobial agents, 2012, 39.2: 105-114. 50