National Strategy and Action Plan on Antimicrobial Resistance 2017-2020

Antimicrobial Resistance National Strategy and Action Plan for the Cayman Islands May 2017 Report 2017-2020 Foreword Antimicrobial medicines are used around the world to treat infections of all types, both in animals and in humans. Resistance to antimicrobials has been gradually evolving since the introduction of the first antibiotics, the Penicillins; however, recent times have seen antimicrobials becoming less and less effective, with many everyday infections or diseases being untreatable and causing mortalities. According to the World Health Organization (WHO), we are currently facing a global health crisis, as antimicrobial resistance (AMR) becomes increasingly present and we run the risk of returning to a pre-antibiotic era. The WHO estimates that unless drastic measures are taken to reduce antimicrobial resistance, in 2050, antimicrobial resistance will be the largest cause of death worldwide, causing the death of 10 million people annually. The main contributing factor in the increase in antimicrobial resistance has been the chronic overuse and imprudent use of antibiotics across the human and animal health sectors. In May 2014, the WHO developed a global action plan to be implemented in 2017 to reduce the use of antimicrobial agents and control the emergence and spread of resistance. In alignment with this global action plan, nations are called on to develop national action plans which wil l incorporate five main strategic objectives: 1. Improve awareness and understanding of antimicrobial resistance through effective communication, education, and training 2. Strengthen the knowledge and evidence base through surveillance and research 3. Reduce the incidence of infection through effective sanitation, hygiene, and infection prevention measures 4. Optimise the use of antimicrobial medicines in human and animal health 5. Develop the economic case for sustainable investments that takes account of needs of all countries, and increase investment of new medicines, diagnostic tools, vaccines, and other interventions This action plan recognises that AMR is a "one health" problem, and highlights the need for an effective "one health" approach. Subsequently, it has been developed because of a coordinated and collaborative effort among major stakeholders and actors, namely government representatives from; public health, agriculture/animal health, environmental health, pharmacy, infection control, and laboratory services. The action plan also recognises achievements and gains made by the Cayman Islands as it relates to AMR and the five strategic objectives outlined above. Other aspects addressed within the action plan speak to the resources available to combat AMR, economic factors related to AMR, drivers of AMR, and a detailed analysis of what needs to be done to further mitigate the problem. AMR cannot be eradicated, and will remain a force to contend with for the foreseeable future. However, a multi­ disciplinary approach to increase knowledge, education, surveillance, research, and governance surrounding AMR will limit its risks and minimise its impact on health, economics, and societal welfare, both now and in the future. Given the severity of this issue, it will be imperative that all sectors respond to the call for action as outlined in this action plan if we are to successfully address this public health threat and preserve the future healthcare ofThe Cayman Islands. ~l;nMBE,JP, MLA Premier of the Cayman Islands Minister of Home Affairs, Health, and Culture 0 Tab e of Contents Foreword 1 Table of Contents 2 Glossary 3 Abbreviations and acronyms 5 Executive Summary 6 Background 8 Introduction 8 Situational analysis 10 Country response 17 Governance 17 Strategic plan 18 Operational plan and budget 24 Monitoring and evaluation plan 25 References 26 Appendices 1. Extended technical working group 2. Survey: Antibiotics and Antimicrobial Resistance in the Coymon Islands 3. Survey: Antimicrobials and Healthcare Professionals in the Cayman Islands 4. Cayman Islands Health Services Authority {H.S.A.) Antibiogrom January 2012- December 2016 5. Photo of Antimicrobial Resistance National Action Plan Development Working Group for The Cayman Islands Glossary Antibiogram An antibiogram is the result of a laboratory testing for the sensitivity of an isolated bacterial strain to different antibiotics. An antibiogram indicates whether the pathogen in question is resistant or sensitive to the antibiotic used in the test. Antibiotic(s) Antibiotics are naturally occurring or artificially produced substances that can kill bacteria (bactericidal effect) or inhibit their growth (bacteriostatic effect). Antibiotics are used in human and veterinary medicine to treat bacterial diseases. They are not effective in viral diseases (e.g. colds and flus). Antimicrobial A drug that selectively destroys of inhibits the growth of microorganisms. Sometimes referred to as an 'antimicrobial agent'. Examples include antibiotics (also known as antibacterials), antiviral, and antifungal agents. Antimicrobial Antimicrobial resistance occurs when microorganisms such as bacteria, viruses, fungi, resistance (AMR) and parasites change in ways that render the medications used to cure the infections they cause ineffective. When the microorganisms become resistant to most antimicrobials they are often referred to as "superbugs". Antimicrobial resistance is the broader term for resistance in different types of microorganisms and encompasses resistance to antibacterial, antiviral, antiparasitic and antifungal drugs. Antimicrobial The use of coordinated interventions to improve and measure the use of antimicrobials by stewardship promoting optimal drug regimen, dose, duration, and route of administration. The aim is for (AMS) optimal clinical outcome and to limit selection of resistant strains. This is a key component of a multi-faceted approach to preventing AMR. Communicable An infectious disease transmissible (as from person to person) by direct contact with an disease affected individual or the individual's discharges or by indirect means (as by a vector). Incidence The occurrence, rate, or frequency of a disease. Microorganism A microorganism is a microscopic creature which can usually not be seen by the naked eye. They include some fungi, single-cell parasites, bacteria, and viruses. Monitoring Monitoring is a continuous process of recording, administering, analysing, summarising and reporting data on the status, for instance the resistance situation, in a population over a given time. The purpose is to identify changes in the situation in order, for example, to check the effect of measures. 'One Health' Collaborative multi-disciplinary work at local, national, and global levels to attain optimal approach health for people, animals, and the environment. Pathogen/ A pathogen is defined as an organism that causes disease. Pathogenic refers to the ability of Pathogenic an organism to produce or cause disease. Penicillin In 1928 Alexander Fleming discovered that fungi of the Penicillium genus kill germs. The antibiotic developed as a result, penicillin, is the oldest antibiotic in clinical use. Penicillin was the first drug available to doctors to treat infectious diseases. It has a relatively narrow spectrum of action, and many bacteria are naturally resistant to penicillin. However, it can still be used successfully to treat various diseases. A number of derivatives have been developed from this active ingredient. They all belong to the Penicillins class. Phenomenon A fact or event of scientific interest susceptible to scientific description and explanation. 3 Prevalence The frequency of a disease or symptom in a population at a given time. Prevention Preventing or minimising future disorders, impairments or damage in order to prevent problems. The aim of disease prevention is to apply targeted measures in order to prevent the occurrence of disease. Stakeholder A stakeholder is defined as an individual or group with a justified interest in the course or outcome of a process or project. Surveillance Surveillance is a three-stage process, the first of which consists of ident ifying and recording diseases (monitoring). In the second stage the data obtained are assessed. After this, consideration is given to what measures need to be taken to contain or prevent a medical problem such as an infectious disease. Vaccination A vaccination is a preventive measure against infectious diseases. Administration of dead or weakened pathogens or parts of pathogens mimics a natural infect ion. This triggers the body's immune system to produce defensive substances that subsequently protect the person who has received the vaccination against the disease in question for a certain time. Zoonosis/Zoonotic A disease that normally exists in animals but that can spread to humans. Examples include Brucellosis, Anthrax, and Lyme disease. The term 'zoonotic' pertains to zoonosis. 4 Abbreviations and acronyms AMR Antimicrobial Resistance AMS Antimicrobial Stewardship AMU Antimicrobial Use CARP HA Caribbean Public Health Agency CPD Continuing Professional Development FOA Food and Agriculture Organisation GLASS Globa l Antimicrobial Resistance Survei llance System IPC Infection Prevention and Control JCI Joint Commission Internationa l M&E Monitoring and Evaluation NAP National Action Plan NAPDWG National Action Plan Development Working Group OIE World Organisation for Animal Health PAHO Pan-American Health Organisation so Strategic Objective SOPs Standard Operating Procedures WHO World Health Organisation WHA World Health Assembly s Executive Summary The discovery and subsequent development of antibiotics (the major class of antimicrobial) has been classified as one of the most important achievements in medical science. These drugs have allowed us to cure serious diseases such as pneumonia and septicaemia, which often proved fatal in the pre-antibiotic era. However, excessive and sometimes non-judicious use of antibiotics and other antimicrobials has led to increasing resistance to the agents which once killed and stopped them in their tracks. The problem of increasing antimicrobial resistance (AMR) not only affects human medicine, but also impacts veterinary medicine, agriculture, and the environment. Drug resistant microorganisms can circulate in populations of humans and animals, through food, as well as through water and the environment. Transmission is influenced by social and economic interactions such as trade, travel, human migration, and animal migration. Bearing this in mind, a joint, cross-sector approach is vital if the associated challenges of AMR are to be faced. Following the WHO's appeal to prioritise AMR as a major public health issue, and to subsequently develop a national action plan to mitigate the surrounding risks of AMR, this document has been made possible through close cooperation among the bodies involved representing human/ public health, animal health/agriculture, environmental health, pharmacy, and microbiology/laboratory services. Other directly affected stakeholders have also been involved to ensure that the content is as broadly supported as possible. These include in particular universities which offer medical programmes, representatives of various government sectors/departments, and other key associations and individuals. The main objectives of this national action plan mirror the strategic objectives set out by the WHO, and revolve around filling knowledge gaps on AMR among the genera l public and public hea lth professionals, conducting surveillance to get a true picture of the AMR burden across all sectors, and ensuring that antibiotics and other antimicrobials remain safe and effective for human and animal use in the long term. The key issues are as follows: Information and education: Gaps in knowledge and information surrounding the development of AMR and possible preventive measures must be closed so that antimicrobials (particularly antibiotics) are used responsibly and only when warranted. This means providing targeted information to specialists such as doctors, veterinarians, pharmacists, farmers and food producers, as well as to the general public. Surveillance: Collecting and maintaining information regarding AMR incidence, prevalence, and trends must be done in order to better understand AMR drivers and patterns. Emphasis on surveillance and evidence-based research will inform policies and actions and assist with the creation of regulations 6 surrounding antimicrobial use (AMU). Accurate and comprehensive set of data also aid in monitoring the effectiveness of the measures taken. An integrated approach to surveillance between the human and animal/food sectors is necessary for source trace-back and to aid with prevention measures. Prevention: Preventing infections in human and animal populations is a vita l way to achieve decreases in antimicrobial consumption. Preventive measures such as improved food and personal hygiene practices, utilising vaccines against common diseases, and optimised on-farm management, hygiene and husbandry, and biosecurity are essential. Appropriate use of antimicrobials: If antimicrobia ls (namely antibiotics) are to be used, they must be administered with caution in order to minimise the development of resistance. This rel ies heavily on a high level of expertise among the individuals prescribing or using antibiotics, both within human and animal medicine. Binding rules and restrictions where appropriate, are also necessary, and must be applied consistently t hroughout the country. All settings affected and involved should be systematical ly monitored so that information surrounding the sale and use of antimicrobials and the development and spread of resistance is obtained readily and consistently. Cooperation and Governance: Interdisciplinary and inter-sector coordination is essent ia l in the effort to control antimicrobial resistance. Technical and strategic synergies should be used, and political, scientific, and economic cooperation among the sectors and entities involved must be actively encouraged. The national action plan on AMR must be treated as a live document, with regular review, and its activities and initiatives should be governed by the AMR national action plan development working group (NAPDWG) for the Cayman Islands. Implementation: Full implementation of the action plan will begin once it has been adopted by the government in May 2017. As they were in its creation, key stakeholders will be involved in implementing the AMR national action plan. This process will require regular collaboration and discussion by the NAPDWG, and will also draw upon external technical experts for consultation and involvement where required and appropriate. Thorough analyses of the AMR burdens and drivers within each sector, as well as preparation of a suitable budget to conduct AMR activities and initiatives will be crucial to the implementation process. It may be necessary for particular regu lat ions and policies to be created, laws to be passed, or ordinances to be amended so that the measures referred to in the national action plan can be implemented. Stakeholders will be involved in accordance with the established consultation processes when changes to legislation or ordinances are being drafted and discussed. 7 Background Introduction The phenomenon of antimicrobial resistance (AMR) has been a topical public health issue for many years. When microbes become resistant to medicines, options for treating the diseases they cause are significantly reduced. The resistance of antimicrobial agents is rapidly increasing on a global scale, and hence causes a serious threat to human health, animal health, and environmental health. In reality, AMR threatens to take us back to the pre-antibiotic era, and in doing so, would almost eradicate the medical gains made in the last century. Antimicrobial resistance develops when bacteria and other microorganisms adapt/mutat e, and are subsequently able to survive and grow in the presence of the medicines which would normally kill them (e.g. antibiotics). The development to resistance is strongly linked to the frequency with which antimicrobials are used. Because (e.g. in the case of antibiotics) many antimicrobials belong to the same class/family of medicines, resistance to one specific agent can lead to resistance to an entire class. Resistance developing in one location or organism can also spread rapidly and unpredictably though, e.g. the exchange of generic material between the two organisms, which can negatively affect the efficacy of antimicrobial agents for a range of infections and diseases. Since antibiotics are the most widely used (and abused) of the antimicrobials, much of this action plan covers strategies to mitigate resistance to these drugs. However, many of the actions proposed in this plan are equa lly applicable to antifungal, antiviral, and antiparasitic resistance, and hence resistance in those other microorganisms (fungi, viruses, and parasites). As antimicrobia l resistance (and particularly antibiotic resistance) spreads, we are faced with the reality that very few prospects for the development of new classes of antibiotics exist in the short term. The pipeline of antibiotic development has been rather dry for the past ten years, with only a handful of new drugs on the market, most of which have a limited spectrum of activity. There are several challenges involved in the creation of new antibiotics. Firstly, the highly-effective defense mechanisms and rapidly evolving complex structure of bacteria make it difficult for the development of medicines which can penetrate and kill them. Secondly, the process of testing new medicines can be exceptionally lengthy, and involves finding patients with specialised infections already resistant to the medicines that are typically prescribed. The research and development cost is large, with investors rarely recovering their expenditure. The consequences of resistant microorganisms include longer illnesses, longer hospital stays, increased absenteeism from work, increased mortality rates, decreased protection during surgery and other medical procedures such as chemotherapy, and increased costs for insurance companies, hospitals, and 8 families. Doctors are increasingly using 'last-resort' medications, which are usually more costly and may have more side effects. Some cases of tuberculosis, malaria, and gonorrhea are now resistant even to these 'last resort' antimicrobials. Antimicrobial resistance affects all areas of health, involves a range of sectors, and has an impact on the whole of society. The development of the global action plan on antimicrobial resistance requested by the World Health Assembly {WHA) in May 2014 and the adoption of this global action plan by governments at WHA in May 2015 reflect that there is a global consensus on the severity of AMR. Subsequently, each member country has been tasked with submitting a national action plan on AMR in line with the global plan. To achieve this goal, action plans identify five strategic objectives: {1) to improve awareness and understanding of antimicrobial resistance; (2) to strengthen knowledge through surveillance and research; {3) to reduce the incidence of infection; (4) to optimise the use of antimicrobial agents; and (5) to ensure sustainable investment in countering ant imicrobial resistance. A 'One Health' approach must be taken to meet these objectives and successfully combat AMR, realising that coherent, comprehensive, and integrated act ions involving different sectors {namely human and veterinary medicine, agriculture, finance, environment, and consumers) are necessary and need to be implemented synergistically. This national action plan on AMR in The Cayman Islands sets out key activities and initiatives which w ill be executed and implemented over the next 5-10 years to combat ant imicrobial resistance. The overall action plan wi ll be reviewed at a minimum of every three years. These actions are structured around the five strategic objectives set out in the previous paragraphs, and are tailored to economic and cultural considerations for the country. 9 Situational analysis Country situational analysis on antimicrobial resistance (AMR) Following a regional training workshop in October 2016 on AMR the development of a national action plan on AMR, a detailed analysis of the situation in The Cayman Islands was conducted initially between public health officials and veterinary services. This was done in order to provide baseline information on factors affecting and driving AMR in The Cayman Islands, focusing on achievements, as well as gaps and challenges which exist for each objective to be met in mitigating AMR. Further ratification took place among th e w ider working group for AMR, and the findings of the analysis are outlined below. Human Health ~~~~·---~~~~~~~~~~~~~~~~~~~~~~~~--~-- ----~~~~~ Awareness and understanding of antimicrobial resistance risks and response in human health Achievements: • Observance of International Infection Prevention Week October 16-22 2016 by government hospital staff (continuing medical education presentations on hand hygiene, vaccination benefits, antimicrobial stewardship, and the national antibiogram) • Observance of World Antibiotic Awareness Week November 14-20 2016 (radio appearance by AMR action plan development working group members, AMR Fact sheet publication in major local newspaper) • AMR awareness and antibiotic use survey created for the general public in January 2017 Gaps: • Varying levels of AMR awareness among the general public Training and professional education on AMR in the human health sector Achievements: • Government hospital staff attended a regional training workshop on AMR and AMR national action plan development hosted by PAHO/WHO in October 2016 • The AMR national action plan development working group hosted the first One Health Symposium in Cayman Islands in April 2017. The target audience was human, animal, and environmental healthcare professionals, as well as students pursuing training in these areas Gaps: • Lack of continued professional development (CPD) opportunities for human healthcare workers specifically related to AMR • Lack of an official AMR handbook for healthcare establishments • Lack of information regarding AMR education in curriculum for medical and nursing schools National monitoring system for consumption and rational use of antimicrobials in human health Achievements: • There is a national drug regulatory authority for The Cayman Islands • An antibiogram is produced every six months by the government hospital laboratory, with subsequent dissemination to all local physicians Gaps: • Lack of a system of data collection, reporting, and monitoring on antimicrobial sales or consumption nationally • Lack of a system of data collection, reporting, and monitoring of antibiotic prescribing and appropriate use in a sample of private and public healthcare facilities 10 ·- ·---·-------------~ National surveillance system for antimicrobial resistance in humans J Achievements: i • Th e government hospital laboratory is Joint Commission International (JCI) accredited, with strong testing .1 capacity and state-of-t he-art machinery • There is a Vitek system present at the government hospital laboratory for microbiology and AMR surveil lance • An antibiogram is produced every six months by the government hospital laboratory, with subsequent • Limited AMR surveillance is being done across sectors/healthcare faci lities • Limited collaboration takes place between existing laboratories on island t ; dissemination to all local physicians Gaps: • T~~~ is a need to regularly contribute AMR data !~~~loba~MR Surveil l a~c: ~Syste~ (GLA S S..:...) .i I Infection prevention and control (IPC) in human health care -·-·----·- ·-·--·--·-· t---· ·-·-·- ·-··-·-·-·---·-- ·-- ·-·---·--·--------------i i Achievements: I • Observance of International Infection Prevention Week October 16-22 2016 by government hospital staff (continuing medical education presentations on hand hygiene, vaccination benefits, antimicrobial stewardship, and the national antibiogram) • There is a national IPC policy/plan available for the Cayman Islands • Al l relevant infection control measures are implemented at the government hospital and associated district clinics • IPC policies, SOPs, guidelines, and protocols at the government hospital and associated district clinics are monitored annually • Presently there are exceptional national percentage values (>92%) for third-level immunisation coverage with pneumococcus vaccine and the Haemophilus influenza type b(Hib) vaccine • Annual submissions are made to PAHO with respect to immunisation coverage as per the vaccination schedule from birth to 18 years of age Gaps: • Lack of internal publishing of information on compliance and effectiveness of IPC practices at the government hospital and associated district clinics on an annual basis • Lack of information regarding t he IPC policies, SOPs, guidelines, and protocols in use at major private hospitals and patient care centers • Lack of information on IPC policies, SOPs, guidelines, and protocols in congregate settings (e.g. nursing/retirement homes, medical and veterinary student dorms, prisons, immigration detention I ~ ce n ters, children' s homes, etc.) ·---' Antimicrobial stewardship and regulation in human health Achievements: • Observance of International Infection Prevention Week October 16-22 2016 by government hospital staff (continuing medical education presentations on hand hygiene, vaccination benefits, antimicrobial I stewardship, and the national antibiogram) · • There is a national drug regulatory authority for The Cayman Islands • • • Gaps: • • An institutional essentials medicines list exists at t he government hospital There are standard treatment guidelines at the government hospital for use of antimicrobial agents in humans I Healthcare provider survey created and disseminated in March 2017 to medical doctors, dentists, and ·1 veterinarians to ascertain most commonly-prescribed/used antimicrobials, and decision-making for antimicrobial choice ! The government hospital lacks a formal multidisciplinary antimicrobial stewardship team to oversee the prescribing practices and use/administration of antimicrobials, monitor resistance patterns, and take steps to mitigate the spread of resistance microorganisms II Lack of a national policy with associated regulations that addresses appropriate use, availability, and ·-------'---'---------"'----------..!....!...----''----......:...-----'-'-----l 11 quality of antimicrobials in the community and in health care settings • Lack of an official AMR handbook for healthcare establishments • Lack of coordination between monitoring and surveillance results in order to inform action and update treatment guidelines and essential medicines lists • Lack of legislation and regulations which govern importation, marketing authorisation/sales, and access to antibiotics for human use • For the government hospital, at present there is no review of appropriateness of antimicrobial agents 48 72 hours after administration, i.e. post-prescription review legislation components related to AMR in human health Gaps: • Lack of legislation and regulat ions which govern importation, marketing authorisation/sales, and access I to antibiotics for human use J Food and Animal Health Awareness and understanding of antimicrobial resistance risks and response in animal health and food production Achievements: • Observance of International Infection Prevention Week October 16-22 2016 by government hospital staff (continuing medical education presentations on hand hygiene, vaccination benefits, antimicrobial stewardship, and the national antibiogram} • Observance of World Antibiotic Awareness Week November 14-20 2016 (radio appearance by AMR action plan development working group members, AMR Fact sheet publication in major local newspaper) • AMR awareness and antibiotic use survey created for the general public in January 2017 Gaps: • Limited knowledge of the animal-related contributions to AMR among livestock and pet owners Training and professional education on AMR in the veterinary sector Achievements: • Government Veterinary Services attended a regional training workshop on AMR and AMR national action plan development hosted by PAHO/WHO in October 2016 • The AMR national action plan development working group hosted the first One Health Symposium in Cayman Islands in Apri l 2017. The target audience was human, animal, and environmental healthcare professionals, as well as students pursuing training in these areas Gaps: • Lack of continuing professional development (CPD} opportunities for veterinarians and veterinary para­ professionals on AMR • Lack of an AMR handbook for all veterinary establishments • Lack of information regarding AMR education in the local veterinary school curriculum 12 National monitoring system for antimicrobial use in animals Achievements: • The Ministry of Agriculture/Department of Agriculture is the sole importer of commercial livestock feed on island • Since 2006, there has been a policy in favour of the importation of livestock animal feeds which are hormone and antibiotic-free • 98% of antimicrobial use is under veterinary supervision • There are no over-the-counter sales of antibiotics to farmers or pet owners • An OIE-initiated survey on antibiotic use in animals for the year 2014 was completed in February 2017 Gaps: • There is a small percentage {potentially less than 2%) of illegal importation of antimicrobials from USA and Latin America; i.e., without a veterinary prescription • Lack of current and consistent information related to antimicrobial use/sales in animal species in the Cayman Islands • Need for a system of data collection, reporting, and monitoring on antimicrobial sales or consumption nationally for livestock animals • Need for a system of data collection, reporting, and monitoring of antibiotic prescribing and appropriate use in a sample of private and public veterinary healthcare faci lities (e.g. a national animal drug regulatory authority) National surveillance system for antimicrobial resistance in animals and foods Gaps: • Lack of laboratory capacity for AMR screening • No AMR testing programme in animals or foods of animal origin • No information is available on priority pathogens for animals as it relates to AMR • No information is available on priority food pathogens as it relates to AMR Infection prevention and control in animal health Achievements: • A Veterinary biosecurity SOP document exists for government veterinary services field staff • There is strong, continuous promotion of good hygiene practices along the food chain • There is continuous promotion of on-farm biosecurity and hygiene practices to minimise infection and the need for antimicrobial use in livestock animals Gaps: • There is a need for greater 'buy-in' among livestock farmers as it relates to adequate farm hygiene, biosecurity, appropriate vaccination, and appropriate handling of sick animals to prevent transmission of resistant bacteria to other animals and humans Antimicrobial stewardship and regulation in animal health Achievements: • Healthcare provider survey created and disseminated in March 2017 to medical doctors, dentists, and veterinarians to ascertain most commonly-prescribed/used antimicrobials, and decision-making for antimicrobial choice Gaps: • To develop and implement a national policy with associated regulations for antimicrobial stewardship that addresses appropriate use, availability, and quality of antimicrobials for animals • There is need for a national AMR handbook for veterinarians and veterinary para-professionals • Lack of monitoring and surveillance of AMR to guide updating of an essentials medicines list for animals • There is a need for standard t reatment guidelines for the use of antimicrobial agents and standard treatment recommendations in animals ~-~~~~~~~~~~~~~~~~~~~~~~~~~~~ 13 • Lack of legislation and regulations governing importation, marketing authorisation/sales, access to, and prudent use of quality medicinal products for animal use based on international standards (e.g., the OIE) Legislation components related to AMR and animal health Gaps: • The national slaughter regulations are outdated and have yet to be passed by cabinet • The current Animals Law is in need of updating and subsequent approval by cabinet • There is little enforcement of the Animals Law and a lack of cohesion between the police force and the Department of Agriculture • Lack of legislation and regulations which govern importation, marketing authorisation/sales, access to, and prudent use of quality medicinal products for animal use based on international standards (e.g., the OIE) Plant and crop production and health Awareness and understanding of AMR in plants and crops Achievements: • Observance of World Antibiotic Awareness Week November 14-20 2016 (radio appearance by AMR action plan development working group members, AMR Fact sheet publication in major local newspaper) • The Cayman Islands, along with other Caribbean countries, through the Caribbean Group of Pesticide Boards (CGPC), observes Pesticide Awareness Week annually during the week containing the 27th September Gaps: • There is still much uncertainty surrounding the impact of plant/crop farming on AMR in The Cayman Islands (it is currently thought that the impact is minimal, given product use regulations and the small cro farming sector) Training and professional education on AMR in the plant sector Achievements: • The AMR national action plan development working group hosted the first One Health Symposium in Cayman Islands in April 2017. The target audience was human, animal, and environmental healthcare professionals, as well as students pursuing training in these areas • Safe use and handling of pesticide products workshop held annually and is attended by participants from government and privately-owned nurseries, pest control companies, farm hands, landscapers, and the mosquito research and control unit Gaps: • There currently is no committee which allows interaction between plant and crop stakeholders (e.g. landscapers, nursery owners, hardware store owners, etc.) • It is estimated that there are varying levels of AMR and IPC knowledge/awareness among staff at plant and crop establishments National monitoring system for and rational use of antimicrobials within the plant sector Achievements: • Presently, imported fertilisers (via the Department of Agriculture) do not contain antimicrobials • Presently, there is no importation (via the Department of Agriculture) of antibiotics for use on plants Gaps: • There is still much uncertainty surrounding the impact of plant/crop farming on AMR in The Cayman Islands (it is currently thought that the impact is minimal, given product use regulations and the small crop farming sector) 14 National surveillance system for antimicrobial resistance in plants Gaps: • No AMR testing programme in crops and plants currently exists • There is still much uncertainty surrounding the impact of plant/crop farming on AMR in The Cayman Islands (it is currently thought that the impact is minimal, given product use regulations and the small crop farming sector) Infection prevention and control in the plant sector Gaps: • Lack of a national plant IPC policy/SOP • Lack of a monitoring system for IPC policies, SOPs, guidelines, and protocols at nurseries and farms on island ·--~------------------------------------~-~ Antimicrobial stewardship and regulation for plant health ·-·----~--------------------------------------! Achievements: • Presently, imported fertilisers (via the Department of Agriculture) do not contain antimicrobials • Presently, there is no importation (via the Department of Agriculture) of antibiotics for use on plants Gaps: • There is still much uncertainty surrounding the impact of plant/crop farming on AMR in The Cayman Islands {It is currently thought that the impact is minimal, given product use regulations and the small crop farming sector) Environmental health Awareness and understanding of AMR and its effects on the environment ·-------·--------------- ----------------- ---! Gaps: • There is limited knowledge surrounding the levels of antibiotics, biocides (disinfectants, antiseptics, preservatives), and heavy metals (particularly silver, copper, and zinc) in the soil, sediment, and coastal waters ln The Cayman Islands • There is need for further investigation as to the impact of AMR on the environment ofThe Cayman Islands Training and professional education on AMR in the environment sector Achievements: • The AMR national action plan development working group hosted the first One Health Symposium in Cayman Islands in April 2017. The target audience was human, animal, and environmental healthcare professionals, as well as students pursuing training in these areas Gaps: • There is a lack of specialised AMR training and education for persons working in the environment sector National surveillance system for antimicrobial resistance in the environment Gaps: • Surveillance of antimicrobial resistance and consumption of antibiotics is virtually non-existent as it relates to environmental health • There ls a need to identify relevant environmental pathogens and monitor AMR data, particularly as it :..~lates to mu~s ipal!'.'as~~ate~! hospital waste effluent, and soil 15 Antimicrobial stewardship and regulation for environmental health Achievements: • There is some protection of ground water as it relates to sewage and industrial effluent disposal via planning regulations, trade and business license governance, the Department of Environmental Health's functions, and the functions of the local Water Authority . • Gaps: • There is need to develop regulations which limit discharge of antimicrobial residues into the environment (including pharmaceutical waste} • There is a need for national policies/SOPs (for the general public, as well as healthcare facilities} for the disposal of pharmaceutical waste • There is need to develop a regulatory compliance system that includes compliance with regulations on antimicrobial residues ---------- --------------------------------' Overview and analysis of surveillance data While the impact of AMR in The Cayman Islands has not yet been quantified, antibiogram data for the government hospital shows that resistance is present. This data is produced every six months, focusing on major organisms cultured from a range of samples. Since 2012, antibiogram data has been disseminated to all public and private medical physicians, and subsequently, decreases in resistance patterns have been evident for most major organisms within this time period. Summary data is as follows: (refer to Appendix 4 for Antibiogrom doto for the 2012-2016 period). Enterococcus faecalis: The highest levels of resistance seen from 2012-2016 were to Ciprofloxacin and Levofloxacin, with approximately 30% of samples submitted exhibiting resistance to both antibiotics Haemophilus inf/uenzae: Moderately-high levels of resistance (>40%) to Ampicillin was seen in 2012. Resistance levels in subsequent years have exhibited an undulating pattern. Moderate ly-low resistance patterns (<25%) have been seen with Azithromycin and Augmentin Klebsiella Pneumoniae: Extremely-high resistance levels (68%-82%) to Nitrofurantoin have been consistent between 2012 and 2016. The organism has repeatedly shown low resistance levels (<20%) to all other major antibiotics Proteus mirabilis: The highest resistance levels exist for Ampicillin (approximately 20%), with moderately-low resistance levels to Augmentin and Trimethoprim/Sulfamethoxazole Staphylococcus aureus: Extreme levels of resistance to Erythromycin (>50%), and high resistance to Ciprofloxacin, Oxacillin, and Clindamycin have been consistent over the four year period Pseudomonas aeruqinosa: Highest resistance levels exist for Ciprofloxacin, however, the levels have stead ily decreased between 2012 and 2016 Escherichia coli: Extremely high and consistent resistance levels exhibited for Ampici llin throughout the four-year period, with moderate resistance figures for Ciprofloxacin and Trimethoprim/Su lfamethoxazole 16 Country Response Governance National strategies, policies, and action plans have higher implementation success rates when their development is inclusive of all relevant stakeholders. Transparent governance and oversight are also essential at all stages of the preparation and sustainable implementation of such plans. Early on in the planning process for development of a national action plan for AMR in The Cayman Islands, it was decided that a core working group consisting of the three government representatives who attended regional training on AMR would exist, as wel l as a wider working group consisting of representatives from relevant sectors and departments within human, animal, and environmental health. A list of technical experts to consult was also created, which included tertiary medical institutions, private sector entities, voluntary organisations, and wider governmental departments such as customs, immigration, commerce, and the judiciary. In order to establish and maintain sound governance of the action plan, it was decided that the plan would: • be officially approved by the government and published with open access to the general public • have a dedicated budget for implementing the outlined activities with long-term investment to ensure sustainability • align itself to a national health plan and other human, animal, plant, and environmental healt h strategies and food safety strategies • have incremental targets, ensuring implementation in a stepwise manner to meet both local needs and global priorities • be updated regularly, at a minimum of every 5 years, and be accompanied by a national AMR progress report regarding its implementation • meet intergovernmental standards where relevant (e.g. Codex, OIE Code) National AMR working group In January 2017, a national, multi-sectoral working group was created to develop the action plan for antimicrobial resistance. Members of the government-led working group include representation from Ministry of Health, relevant departments of the government hospital (public health, infection control, microbiology, and pharmacy), as well as the Department of Agriculture and the Department of Environmental Health. The goals of the working group have been to ensure that a 'one health' approach is taken to AMR, as well as to oversee AMR strategic interventions and lobby for implementation of the national action plan. Technical advisement of the committee has mainly been provided by regional PAHO/WHO representatives. Following submission of the national action plan on AMR (May 2017), t he working group aims to meet quarterly (or more frequently if required) to discuss AMR activities, goals, project deadlines, and other related business. 17 Strategic Plan The overall goal of the action plan is to ensure the continuity of the ability to treat and prevent infectious diseases through the effective and safe used of quality-assured medicines, used in a responsible way by those who need them. To this end, the five strategic objectives (50s) as outlined by the WHO are as follows: 1. Improve awareness and understanding of antimicrobial resistance through effective communication, education, and training 2. Strengthen the knowledge and evidence base through surveillance and research 3. Reduce the incidence of infection through effective sanitation, hygiene, and infection prevention measures 4. Optimise the use of antimicrobia l medicines in human and animal health 5. Develop the economic case for sustainable investments that takes account of needs of all countries, and increase investment of new medicines, diagnostic tools, vaccines, and other interventions What follows is a detailed outline of strategic interventions and activities which will be implemented and executed over the next three years. Bearing in mind the priority of AMR drivers/contributors, the largest focus has been placed on human and animal health, with moderate focus placed on environmental health, and minimal focus placed on the plant/crop sector. Strategic Objective One: Improve awareness and understanding of antimicrobial resistance through effective communication, education, and training Objectives: • Identify clear terminology on AMR which can be used and understood by all • Conduct regular nationwide awareness campaigns on AMR with the aim of changing general practices, behaviours, and perceptions as it relates to antimicrobials and their use by consumers, as well as those directly involved in human health, animal health, and agriculture • Use the media, government websites, and social networking sites to promote and increase national awareness of AMR and to deliver messages to train the agents of change • Include antimicrobial resistance in undergraduate curricula for medical doctors, veterinarians, and nurses • Include antimicrobial resistance as part of continuing professional development for all sectors and professionals in human health, animal health, agriculture, and environmental health • Include AMR and hygiene/biosecurity presentations in annual livestock farmer seminars 18 Specific interventions and activities with proposed deadlines: • Participate in and promote AMR through World Antibiotic Awareness Week on an annual basis • Assess AMR education as part of curriculum for the local medical school, veterinary school, and nursing school. Provide appropriate recommendations to the Ministry of Education and to each institution regarding necessary implementations o Milestone: July 2017 • Create a detailed report on the knowledge and use surrounding antimicrobials and antimicrobial resistance, using data collected from general public and healthcare practitioners' surveys conducted in early 2017 o Milestone: October 2017 • Host a One Health Symposium on an annual basis, which features AMR and other relevant public health topics for the education and sensitisation of the genera l public, as well as professionals in One Health arenas • Determine AMR education at private nurseries and landscaping companies. Provide appropriate recommendations to each institution regarding necessary implementations o Milestone: October 2017 • Develop an AMR handbook for use within human healthcare establishments which includes information on antimicrobial treatment guidelines o Milestone: December 2017 • Develop an AMR handbook for use by veterinarians and veterinary para-professionals which includes information on antimicrobial treatment guidelines o Milestone: December 2017 • Create a One Health website for the Cayman Islands which features information on AMR o Milestone: January 2018 • Create a committee which allows interaction between national plant and crop stakeholders, and where AMR and other relevant topics can be discussed o Milestone: March 2018 Strategic Objective Two: Strengthen the knowledge and evidence base through surveillance and research Objectives: • Fill gaps in knowledge as it relates to the incidence, prevalence, and drivers of AMR in human and animal populations, as well as in the environment • Ensure key players understand how resistance develops and spreads, and how it can circulate within and between humans and animals, as well as through food, water, and the environment 19 • Define national objectives and standards across all sectors for the surveillance of antimicrobial resistance and a list of priority pathogenic, zoonotic, commensal, and indicator organisms • Ensure harmonisation between human and animal laboratory testing methods and surveillance sampling methods • Strengthen AMR data collection across all sectors, applying an integrated surveillance approach between human clinical samples, animal samples, and foods of animal origin. • Ensure national surveillance and diagnostic tools and methods remain current across all sectors • Maintain JCI accreditation for the government hospital laboratory • Conduct and publish results from basic research to support AMR objectives • Conduct and publish results from research identifying alternatives to nontherapeutic use of antimicrobia ls in agriculture • Conduct and publish economic research which assesses the cost/impact of antimicrobial resistance, as well as the costs and benefits of implementing the outlined national action plan Specific interventions and activities with proposed deadlines: • Share information on national antimicrobial resistance research at the annual One Health Symposium • Contribute AMR data to the Global Antimicrobial Resistance Surveillance System {GLASS) on an annual basis • Build on the current government hospital laboratory's antibiogram to include antibiotics not conventionally reported o Milestone: October 2017 • Identify two priority an imal health pathogens and collect, report, and monitor AMR data on an annua l basis o Milestone: December 2017 • Submit samples of key organisms to CARPHA on a quarterly basis for antimicrobial sensitivity testing, and to assist with ascertaining the level of resistance present within the region o Milestone: January 2018 • Through the national communicable disease surveillance group, establish a national disease surveillance technical group with terms of reference to develop a national One Health surveillance system to include routine surveillance, sentinel surveillance, and surveys o Milestone: January 2018 • Update national slaughter regulations and submit to cabinet for approval o March 2018 20 • With a focus on municipal wastewater, hospital waste effluent, and soil, identify relevant environmental pathogens and collect, report, and monitor AMR data on an annual basis o Milestone: June 2018 • Identify relevant food pathogens and collect, report, and monitor AMR data on an annual basis o Milestone: June 2018 • Invest resources in studies for wastewater sites and their effect on the spread of AMR microorganisms o Milestone: October 2018 • Establish a national reference laboratory where foodborne and animal pathogens can be analysed, and where antimicrobial resistance research and antimicrobial sensitivity testing can take place o Milestone: January 2019 Strategic Objective Three: Reduce the incidence of infection through effective sanitation, hygiene, and infection prevention measures Objectives: • Continue to promote strong hygiene practices and infection prevention measures such as hand washing • Continue to promote and educate the general public regarding food preparation and water safety • Strengthen, and continue to advocate for and encourage the use of appropriate vaccination as an infection prevention measure • Maintain current national percentage values, and seek to improve values for immunisations as per the PAHO immunisation schedule/guidelines • Continue to promote sustainable animal husbandry practices, strong on-farm hygiene and biosecurity, as well as stress-free handling of animals • Promote safe sexual practices to prevent infections transmitted through bodily fluids • Promote good dietary nutrition and healthy lifestyle practices as a means to prevent infections and the need for antimicrobials Specific interventions and activities with proposed deadlines: • Participate in and promote International Infection Prevention Week activities on an annual basis • Internally publish information on compliance and effectiveness of IPC practices at the government hospital and associated district clinics on an annual basis • Assess IPC education as part of curriculum for the local medical school, veterinary school, and nursing school. Provide appropriate recommendations to each institution regarding necessary implementations and review every two years o Milestone: July 2017 21 • Review IPC policies/SOPs/guidelines/protocols for major private hospitals and healthcare facilities. Provide recommendations/templates where necessary and review every two years o Milestone: October 2017 • Review IPC policies/SOPs/guidelines/ protocols for congregate settings. Provide recommendations/templates where necessary and review documentation every two years o Milestone: October 2017 • Update 'Standards of Care' documents for all animal species, and create regulations surrounding best practice for animal rearing for submission to cabinet o March 2018 Strategic Objective Four: Optimise the use of antimicrobia l medicines in human and animal health Objectives: • Educate clinicians, veterinarians, and pharmacists in order to eliminate unnecessary dispensing of antimicrobial, and hence increase their longevity • Continue to place restrictions on non-therapeutic use of antibiotics within agriculture • Maintain high levels of inspection vigilance at borders for the illegal/non-judicious importation of antimicrobial medicines/ products • Increase regulation related to antibiotic distribution, quality, and use to aid in preserving effectiveness of antibiotics • Encourage relevant stakeholders to regularly consult OIE resources on antimicrobial agents of veterinary importance • Encourage relevant stakeholders to regularly consult WHO resources on essential medicines of human health importance Specific interventions and activities with proposed deadlines: • Collect data on antibiotic use in animals on an annual basis in order to develop a national database on antibiotic use in animals and report to the OIE as necessary • Create a national policy which speaks to the general public, as well as to healthcare providers as it relates to the safe disposal of medicines and pharmaceutical waste o Milestone: October 2017 • Establish an antimicrobial stewardship team for the government hospital consisting primarily of microbiology, infection control, public health, and pharmaceutical personnel o Milestone: December 2017 22 • Implement a system of data collection, reporting, and monitoring on antimicrobial sales or consumption nationally for human healthcare establishments and pharmacies o Milestone: January 2018 • Implement a system of data collection, reporting, and monitoring of antibiotic prescribing and appropriate use in a sample of private and public healthcare facilities o Milestone: January 2018 • Establish a national stewardship programme for the animal sector o Milestone: March 2018 • Create Veterinary drug legislation for submission to cabinet o Milestone: March 2018 Strategic Objective Five: Develop the economic case for sustainable investment that takes into account the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines, and other interventions Objectives: • Via the AMR national action plan development working group (NAPDWG), continue to implement, execute, coordinate, and lobby for antimicrobial resistance activities • Link the national antimicrobial resistance action plan to existing strategic plans from all sectors • Ensure a dedicated secretariat and budget exist for the AMR working group • Continue to identify specific sector issues related to antimicrobial resistance and national action plan implementation • Continue to consult with national, regional, and international technical experts and stakeholders as it relates to the strategical operational plan on antimicrobia l resistance • Ensure international technical collaboration and information sharing on all aspects of antimicrobial resistance • Participate in regional and international collaborative research to support the development of new medicines, diagnostic tools, and vaccines • Develop agreements/regulatory measures to evaluate new vaccines, diagnostic methods, and antimicrobial drugs and include these in country health agendas 23 Specific interventions and activities with proposed deadlines: • Conduct a comprehensive impact analysis on antimicrobial resistance in The Cayman Islands o Milestone: October 2017 • Create a realistic AMR activity and initiatives budget after assessing investment needs, funding sources, and relevant partners to engage o Milestone: December 2017 • Review the OIE Veterinary performance tool as it relates to human resources, staff education, laboratory capacity, and compliance with OIE standards for Veterinary Services o Milestone: April 2018 • Expand the existing public health department to include a 'One Health' representative who will be primarily responsible for One Health initiatives and activities for the Cayman Islands o Milestone: January 2019 • Ensure regular meetings of the AMR NAP development working group; at least quarterly • Provide annual financial contribution to regional or international diagnostic tools or research related to AMR • Review the antimicrobial resistance action plan for the Cayman Islands every three years, or more frequently if necessary Operational plan and budget Several AMR activities have been executed and implemented, and can be identified in the situational analysis section of this action plan. The AMR working group has been deliberate with identifying which individuals, sectors, or institutions will be responsible for which activities, and the proposed deadlines by which these should be achieved. These activities will be continuously reviewed during quarterly working group meetings. Further discussion is necessary regarding the specific calculated budget for implementing each activity, as well as the indicator(s), milestones, and targets that will be used to monitor the execution/implementation of each activity. The budget for AMR activities will originate from the Ministry of Health, Ministry of Agriculture, and other relevant government and private sectors. External funding will be coordinated by the national AMR working group. Appropriate finance/accounting expertise will be sought and engaged in preparing the NAP budget, particularly with regards to procurement, supply, and costing. Information to be clearly indicated in the budget includes: source and funding for each intervention, government contributions, the expected funding gap, ideas to fil l the funding gap, and the activities and strategic interventions required to achieve NAP objectives that are not funded. National action plan development toolkit references and resources from international bodies such as the WHO will also be consulted. The AMR budget will be reviewed every three years in alignment with the overview of the national action plan. 24 Monitoring and evaluation plan Monitoring and evaluation (M&E) are essential managerial and governance functions in health plans. Indicators, targets, baselines, data collection methods, and responsible entities have been and will continue to be identified in order to provide a comprehensive framework for the progress made in implementing planned AMR activities (monitoring), as well as the progress made in achieving intended AMR goals and objectives (evaluation). Locally appropriate outcome indicators will be feasible, tangible, easy to measure, and will highlight positive momentum, or obstacles in the implementation process. The national action plan on AMR will rema in a live document, and a process of review and revisiting while activities and initiatives are being implemented wil l take place via t he AMR NAPDWG. As part of SOS, a national AMR progress report will be published within five years after adoption of this action plan. This report will allow any required changes to the implementation process to be made, and will intend to answer the following questions in particular: • Have the targets been achieved? Can they be achieved? • Were the timeframes/milestones realistic? • Were the correct implementation steps taken? • Are the instruments and measures effective and efficient? • What consequences can be drawn and what recommendations can be made in respect to the results/outcome of each implementation? Key resources for M&E will include the following documents: • Monitoring, evaluation and review of national health strategies. A country-led platform for information and accountability. Geneva: International Health Partnership, WHO; 2011 • Sample conceptual monitori ng and evaluation framework for national act ion plans on antimicrobial resistance • WHO M&E framework for AMR, which will include output, outcome, and impact indicators 25 References 1. A framework for national health policies, strategies and plans. Geneva: WHO; 2010 (http://www.who.int/nationalpolicies/FrameworkNHPSP final en.pdf). 2. Antimicrobial Resistance: A manual for developing national action plans (FAO, OIE, WHO 2016) 3. Antibiotic Resistance: Handle Antibiotics with care, WHO/PAHO lnfographic, www.who.int/drugresistance 4. Antibiotic resistance: Q&A for WHO spokespeople, November 2016 5. Antimicrobial Resistance and Use in Canada: A Federal framework for action 6. Antimicrobial Resistance: What you need to know, Dorman, S. November 2016 7. Barriere, S.L., PharmD (2015) Clinical, economic and societal impact of antibiotic resistance, Expert Opinion on Pharmacotherapy, 16:2, 151-153 http://www. ta ndfon I ine.com/ doi/pdf /10.1517 /14656566. 2015. 983077?needAccess=true 8. Causes of Antibiotic Resistance, WHO/PAHO lnfographic 9. Economic Aspects of Antibiotic Resistance: A Factsheet from ReAct-Acion on Antibiotic Resistance, May 2008, www.reactgroup.org 10. Global action plan for antimicrobial resistance (World Health Assembly document A68/20, 27 March 2015) (http://www.who.int/drugresistance/global action plan/en/). 11. OIE: (http:// www.oie.int/en/for-the-media/amr/) 12. O'Neill review on Antimicrobial Resistance, 2014, www.amr-review.org 13. Poppy, G., Antimicrobial resistance in the food supply chain, Chief Scientific Adviser's Science Report, Food Standards Agency, UK https://www.food.gov.uk/sites/default/files/csa-amr­ report.pdf 14. Rousseau, 0., FAO to cut antimicrobial resistance in food supply chain, Global Meats news.corn, September 2016 http://mobile.globalmeatnews.com/ lndustry-Markets/FAO-to-cut a ntim icro bia 1-resista nce-in-food-su pply ch a in ?utm source=RSS text news&utm medium=RSS feed&utm campaign=RSS Text News 15. Sample conceptual M&E framework for national action plans on antimicrobial resistance. WHO; 2015. (http ://www.who.int/ drugresistance/action-pla ns/ en/) 16. Strategy on Antibiotic Resistance Switzerland, November 18 2015 17. Template for a national action plan on antimicrobial resistance. WHO; 2015. (http://www. who. int/ drugresistance/action-pla ns/ en/) 18. The Government of Fiji: Fiji National Antimicrobial Resistance Action Plan 2015 19. The World Bank, By 2050, drug-resistance infections could cause global economic damage on par with 2008 financial crisis, September 2016 http://www.worldbank.org/en/news/press­ release/2016/09/18/by-2050-drug-resistant-infections-could-cause-global-economic-damage­ on-pa r-with-2008-fi na ncia I-crisis 26 20. UK Five Year Antimicrobia l Resistance St rategy 2013-2018 21. Union of Concerned Scientists, Prescription for Trouble: Using Antibiotics to fatten Livestock, n.d http://www.ucsusa.org/food and agriculture/our-failing-food-system/industrial agricultu re/prescription-for-trouble. htm I#. WCsORrl rKU k . 22. WHO: (http://www.who.int/drugresistance/en/) 27 Appendices 1. List of technical experts to consult for the development and implementation of AMR activities for The Cayman Islands • Human health o Ministry of Health o Public Health Department o St. Matthews University School of Medicine o Cayman Islands Medical and Denta l Society o Health Practice Commission • Anima l health, welfare, and production including fisheries o M inistry of Agriculture (PLAHI) o Department of Agriculture o St. Matthews University School of Veterinary Medicine o Cayman Islands Agricu lture Society o Cayman Animal Hospital o Island Veterinary Services o The Veterinary Clinic and specialty pet boarding o Cayman Islands Veterinary Medical Association • Food safety and security, including food production and processing o Cayman Islands Customs o Department of Agriculture o Department of Environmental Health • Plants and agriculture o Ministry of Agriculture (PLAHI) o Department of Agriculture o Cayman Islands Agriculture Society o Nurseries/Landscaping companies • Environment, including water and sewage o Department of Environment o Department of Environmental Health o Water Authority Cayman o Cayman Water Company o Mosquito Research and Control Unit • Technica l disciplines o Public Health o Public and Private pharmacies o Public and private laboratories o Infection control coordinator • Others 0 Ministry of Tourism/Department of Tourism 0 Department of Education 0 Ministry of Finance/Commerce 0 Department of Immigration 0 Legal sector/judiciary 0 CINICO and other insurance companies 0 Other Universities (e.g. UCCI, ICC!) o Appropriate voluntary organisations o Regulatory authorities (medicines, agricultural products) 2. Survey: Antibiotics and Antimicrobial Resistance in the Cayman Islands What follows is a survey that was conducted over a two-week period in February 2017. The target audience was the general public of the Cayman Islands, and the objectives of the survey were to gain an understanding of how safely and accurately antibiotics are used on the island, as well as how aware members of the public were regarding antimicrobial resistance {AMR) as a topic, its causes, and how the spread of AMR takes place. Along with a survey targeting healthcare professionals {Appendix 3), this survey will be used to generate a report on antibiotic use and antimicrobial resistance for the Cayman Islands. Antibiotics and Antimicrobial Resistance in The Cayman Islands 1. Are you male or female? Q Maia Q Female 2. Whal is your age? Q 20 or younger 0 21-30 0 3140 0 41-50 0 51-80 Q 61 and older 3. In which district do you reside? Q WestBay Q George Town Q Bodden Town 0 North Side 0 East End 0 Cayman Brae 0 Little Cayman 4. What is the highest level of education that you have completed? Q No schooling completed Q High school or less. no diploma/qualifications 0 High school graduate wnh diploma/qualifications Q Some college credits, no degree Q TechnlcalNocational training OR Associates degree Q Bachelor's degree Q Masters/Professional degree Q Doctorate degree 5. When did you last take antibiotics? 0 In the last month 0 In tile last 6 months 0 In tile last year 0 More than a year ago 0 Never 0 Can't remember 6. On that occasion, did you get the antibiotics or a prescription for them from a doctor? Q Yes Q No Q Not applicable 7. Do you think this statement is true orfalse?- 'It's okay to use antibiotics that were given to a friend or family member, as long as they were used to treat the same illness' Q True Q False 2 8. Which of the following conditions can be treated with antibiotics? Select all that apply. D HIV/AIDS O Gonorrhea 0 Bladder infection or urinary tract infection (UTI) O Diarrhoea O Flu virus O Faver O Malaria 0 Skin or wound infection O Sore throat O Bodyachcs O Headaches O Zlkavirus 9. Which of the following terms are you familiar with/have you heard before? Select all that apply. D Antibiotic resislance D Superbugs D Antimicrobial resistance D AMR D Drug resls1ance D Antlbiotic·reslstant bacteria D MRSA D Multl·drug resistance 3 10. For the terms selected above, where did you hear about them? Select all that apply. 0 Doctor or nurse D Pharmacist D Other healthcare professional 0 Family member or friend (including on social media) D Media (newspaper, TV, radio, social media) 0 Specific campaign D Can't remember 0 Other (please specify) 11. Please indicate which of the following statements you believe to be true. Select all that apply. 0 Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work well 0 Many infections are becoming increasingly resistant to treatment by antibiotics 0 If bacteria are resistant to antibiotics, tt can be very difficult or impossible to treat the Infections they cause D Antibiotic resistance is an issue that could affect me or my family 0 Antibiotic resistance Is an is -;ue in other countries but not In The Cayman Islands 0 Antibiotic resistance is only a problem for people who take antibiotics regularly 0 Bacteria which are resistant to antibiotics can be spread from person to person 0 Antibiotic-resistant infections could make medical procedures l ike surgery, organ transplants, and cancer treatment much more dangerous 0 Antibiotic-resistant infections can be contracted from interaction with o r exposure to animals or animal products (including pets, livestock) 4 12. On a scale of 1-5 (1{extreme left}= disagree strongly, 2= disagree slightly, 3= neither agree nor disagree, 4= agree slightly, 5 {extreme right}= agree strongly), indicate how much you agree that the following actions would help address the problem of antimicrobial resistance. Note that questions relate to the global problem of antimicrobial resistance, and not just the situation in The Cayman Islands 2 3 4 5 People should use antibiotics only when 0 0 0 0 0 they are prescribed by a doctor Farmers and Veterinarians should 0 0 0 0 0 give fewer antibiotics to food-producing animals People should not keep antibiotics and use them 0 0 0 0 0 later for other illnesses Parents should make sure that all their 0 0 0 0 0 children's vaccinations are up-to-date People should wash 0 0 0 0 0 their hands regularly People should wash fruits and vegetables 0 0 0 0 0 before consumption People should cook 0 0 0 0 0 meat thoroughly Doctors should only prescribe antibiotics 0 0 0 0 0 when they are needed Governments should reward the development 0 0 0 0 0 or new antibiotics and vaccines Pharmaceutical companies should 0 0 0 0 0 develop new antibiotics and vaccines 5 13. On a scale of 1-5 (1{extreme left}= disagree strongly, 2= disagree sl ightly, 3= neither agree nor disagree, 4= agree slighUy, 5 {extreme right}= agree strongly), indicate how much you agree with the following statements. 2 3 4 5 Antibiotic resistance is one of the biggest 0 0 0 0 0 problems Iha wo~d laces Medical experts will solve the problem or antibiotic resistance 0 0 0 0 0 before it becomes too serious Everyooe needs to take responsibility for using 0 0 0 0 0 antibiotics responsibly There is not much that people like me can do to 0 0 0 0 0 stop antibiotic resistance I am worried about the impact that antibiotic resistance wal have on 0 0 0 0 0 my heatth, and that of my family I am not at risk of getting an antibiotic-resistant infection. as long as I 0 0 0 0 0 take my antibiotics correctly 14. Do you think that antibiotics are widely used in the rearing of food-producing animals in The Cayman Islands? Q Yes Q No Q Oon'tknow 15. Do you think that antibiotics are widely used in the farming of fnrits and vegetables in The Cayman Islands? Q Yes 0 No Q Oonlknow 6 16. Do you think that antibiotics are widely used in animal products being imported into your country? 0 Yes 0 No 0 Don~ know 17. Do you th ink that antibiotics are widely used in fruits and vegetables imported into your country? 0 Yos 0 No 0 Don't know 7 3. Survey: Antimicrobials and Healthcare Professionals in the Cayman Islands What follows is a survey that was conducted over an eight week period in March 2017. The target audience was medical doctors, dentists, and veterinarians; i.e., those who prescribe antimicrobials in the Cayman Islands. The objectives of the survey were to gather information regarding which antimicrobials are commonly prescribed in human and animal health, as well as the awareness of the antibiogram data which is conducted on a six-monthly basis and disseminated to all human health physicians. As of December 2016, the data is also shared with local veterinarians. Along with a survey targeting the general public (Appendix 2), this survey will be used to generate a report on antibiotic use and antimicrobial resistance for the Cayman Islands. Antimicrobials and Healthcare Professionals in The C11yman Islands 1. Are you male or female? 0 Mile 0 fem&Je 2. What is your age? 0 200<yout~ 0 21·30 0 31-40 0 41-50 0 51-60 Q 61 zndolCer 3. What is your professoon? 0 Medical dOCIOr 0 Oen1ist Q Vel«irla1ian 4. How would you bosl desClibe the environment in which you work? Q l'llllllcpnlcilco Q PnwtepmcllCa 0 °""' !lllease tpedly) 5. How many yoars of work experience have you had sinco gr&dual lon? Q Less tllal 1 >'CUI' 0 •-6yats Q 6-IOyelllS 0 1M5ycors 0 16-20 ye ... Q 21 yeenor""'"' If you are a Veterinarian, please go directly to question 9 (omit questions 6-8) 2 6. For the following situations, select the antibiotic which you would prescribe prophylactically to an adull patient with no allergies. I don'! prescrile entiliotlcs PenidninVK Cllndamycin Amoxicilin Asnoxicillin wi!h clavulanic ac:id O!ha' anlibio!ic NO: applicable ~:::..,.ry ,l ;II ;Jc= iJ L ;JI ;II ;! I ;J roOICMtll Ordybefore e~omio SlX9ef)' f ;! 1 ; 1 I ;I! ;J ; I ;JI ;J HIV posl1ive patients · ~18• positive r - .;:1 r p~ic"ts l ~l . ] I ~l Non· conlltlltod dlnbo!la pe\kmlS l ;II ;JI ;J[ ;I[ ;II ; j [ ;J Congenital heart disea.e(AV I ;) I ; :[ ; l r ;JI ;]( ; ! ( ;] stvm and .. , J J L. ~ t ..-. ':J . Ct":tdia.c v;:;lve replac;e,,.,nl) Hi11oryor c11m:er and/or radlolhOnipy ( ;J'1 ;JI ; I[ ; )[ ;JI ;)[ ;I 7. For the following cond~ions, select the antibiotic you would prescribe lo an adult patient with no allergies. I don"t prescribe a.n!ibiotics Per.lcilllnVK Clinorunyc:in Atn()O(icl rin Amoiddllin vfi!h e,:lavVlanic acid Other antibiotic Notei~)ltcahle Symp!Ol'i'lalit ,----------~ r----~ ~----~ r----~ r-----------~ r-----~ ~----~ :!:on01J ;)[ - iJ[ ; j j ; j[ ; ,[ ;J ; i 3 ldorll~.,,.,- -nVK Cindamyan - AmoJkiln~h~acid o:herai1'illioeit Noe~ :;:;:- 1 : jl :] I ~ : 'I ~ :] I : I < : Clwnle ::..~ [ sh.ls lr8CI Moron root Clllllll ll'OR!lllClll Inn omlilnl wlihfQY!)( ondmnllllllO ··c -- ·r Tj T " :)[" :J( : l :J [ · :J r· = :H lno putkmt .,;111 dllf use swC!lling .. iltfo01e or&I cavtry r . :=iJt :Jr-~r----;i r ~·· pmlont w11111 .. uling l :;::lty :I I :J ~ .:J [ ~ '11 IWO<tisil r- ---, ,.-------, ....., ....,, '1re· ·· :.,.';:!- [~ ---- -~ [ :l ~ ~ :][ :)[ ~~ .:1[ . . :' . J :l :) 4 1 • • '[ --~ · J - • l • j ~~-~[ :J : .' . ; . . "' ptolongOd mo!Cllllll Ull!menl I - :JL =. ] : c-= .:J L - :JI :l: . . 8. For each of the following conditions and diseases, select which antimicrobial agont you would bo most likely lo use. 4 tD D DDC DC['JO DOJODCDO ~ i - - - j ------- - 1D D D D GDDGDDD:D~ LJ D D 10 o o o ooooooo~oc o o o 10 D DD[[JLJ[~LJDDLD[JLJDU 10 D D D CDDDDDDLDD [J D D j o· ··-·1 o· rJ· I .. , [; o· ~1 r·l r:·J rl ····, o· 1·.-., r.-i ['-] o· · - l , --- ··--··' LJ -··- l , J J ~ -·· 10· o· o· o· ro· ro· o· o· llio· 1, I o· o· .. L~ l -~ L J ~.J LJ LJ t O~DDDDLJ 0 DDDDDLJLJO[ ·-.-; ~ '4> ... ,. .,: ... ,. --:(..... ..... ...- .... ..... ..... ... .. .. r-·~ ..... ..,.·1 1 I I I c J lJ 1DCDDDDD D DDDDDD~DG 1ocoooon o 000000~0[ i DCDDDD~ D DDDDDCCDG 11 i D[ClDDD~ D DO DODD CDC H 10LJDDDDLJ 0 DDDDDOGDC H iDODDDDD D DDDDDD[JDO H 2 ~ Avllilnbmty of non- 0 0 0 0 0 pl"llm•cdol1c ~ .. mplcs - - Mode oi action 0 0 0 0 0 Orvgellloacy 0 0 0 0 0 Ourauon of ~C1ion 0 0 0 0 0 - - - -- - Typical response rate 0 0 0 0 0 Spectrum of ac~vity 0 0 0 0 0 - - - - Cul:ure nnd Sansilivhy resuns 0 0 0 0 0 - Cost 0 0 0 0 0 - - - Roslstlll\00 patterns f(I" the 0 0 0 0 0 ruulmiaoblal In questloo Ease o( availability 0 0 0 0 0 Eff•'CI of ootimfC>'Oblal ngenl on co-existing mcxbldftillS OI 0 0 0 0 0 sllefgies Abiliiy to altllf uea1ment plan' remove anUmletObial agem 0 0 0 0 0 from treatment plan based on microbiology resells Cu1Tent research related to the diseosclc<lldttlon in 0 0 0 0 0 ques6an Risk of adverse 0 0 0 0 0 e1ectslevents Patienfs e><1iressed ooed or 0 0 0 0 0 desire for the preso1J!ion Antimiaobi&I p-escri.bBlg 0 0 0 0 0 audits Cooooquences of future 0 0 0 0 0 resistance Consut!alion v;;:h lherapeutic guidefines wittin your 0 0 0 0 0 prac1ice Rnlated pubic henhh 0 0 0 0 0 impflcatloos 8 11. Ate you familiar wfth the regula~y-disseminated antibiogram produced by the Health Services Authority (HSA) Laboratoiy? Q Yes Q No 12. If you are aware of the antibiogram, do you use it 10 make decisions related to drug/prescription choice? Q Yes 0 No 0 NOi l'llPlicablc 9 4. Cayman Islands Health Services Authority {H.S.A.) Antibiogram January 2012- December 2016 Cl Health Services Authority Pathology Laboratory Antibiotic Resistance Enterococcus faecalis (Jan 2012 - Dec 2016) 35 C'I) 30 25 ~ 20 c: IO .... -. !!! 15 rJI Q) a: ~ 10 0 5 0 ().<::'­ '?> ~o-f! ~ 0.s. Antibiotics Cl Health Services Authority Antibiotic Resistance Haemophilus influenzae (Jan 2012 - Dec 2016) 00 50 ,-----------------------------------. 45 +----~..;.. ,:. c.. ...:. ; '-'-,- --"-------1 40 +-------! 35 +-------! Q) 30 +---~---t (.) ~ 25 +--- - ---· -rJI 'iii 20 ~""---~~-t Q) a: 15 ~ 0 10 5 0 -1-1.-L---= • 2012 02013 0 2014 •2015 02016 0 2012 0 2013 •2014 0 2015 • 2016 90 80 70 60 Q) (,) 50 c: co - 40 .!!! t/) 30 Q) ~ ~ 0 20 10 0 25 20 15 Q) u c: ~ 10 .!!! I/) Q) ~ ~ 0 5 0 ·S' ~ ff' "Oj ~ Cl Health Services Authority Pathology Laboratory Antibiotic Resistance Klebsiella Pneumoniae (Jan 2012 - Dec 2016) C\/ ~ ·~ .,s; ~ ~ 112012 02013 02014 • 2015 • 2016 Antibiotics Cl Health Services Authority Pathology Lab Antibiotics Resistance Proteus mirabilis (Jan 2012 - Dec 2016) ·S ~ & ~ !-:: & ·S ..,. .... • 2012 0 2013 i-.-------------------------1 02014 QI QI QI ·S ·S • 2015 • 2016 .p ~ § :k :f .§ .§ ~ .§ ~ ~(/j :k f §. ·~ & ~ f -;fJ & <di ·f!J ~ .§ ~ ~ s CJ $! ~ ~ .:,.0 ·~ ~ ;;J ~ 0QI QI CJ QI /.....,0 f CJ CJ ......,, ~ ;..;, Antibiotics 4..s. Cl) (.) c (Q -.~ "' Cl) 0::: ~ 0 10 0 '1:-..o+·· ~ Cl Health Services Authority Pathology Laboratory Antibiotic Resistance Staphylococcus aureus (Jan 2012 - Dec 2016) .......... c:c ~·· ~· .~~ 0 ~·· ~· ~·· ~o+··· ~o 0 o'l> ~o (}- ~<:' iF' c,O *<:' ~ . ~ ~<:' £' ;t.'l> ~ ~<..~ . .::{l><:' '40 0'V ~c; (;~ c; 0 0 ~'lj 0e; v0 '><:' 0<> ~0 -<..~ 45 CO> 40 '1:1-"' '1:1 35 30 25 20 15 10 5 0 <P '!t-'l> ~o ~o 0~ Antibiotics Cl Health Services Pathology Laboratory Antibiotic Resistance Pseudomonas aeruginosa (Jan 2012 - Dec 2016) "' ~?J "' "-" c ;§ 0 ().~ 0~ ().~ 0 o· ~~ . &<$" ~~ 'lJ<:' -:+-'l> Q~ ~~'V ~'l> ~ {lf ~o~ ~o !<, 'lJ .~~ ~f'(j 'lJ~ (j (;0 ~~ ~0 '40 v0 (;0 (} ~'l> 0 ~~ Antibiotics 19201 2 • 2013 02014 02015 • 2016 • 2012 02013 0 2014 • 2015 • 2016 Q) 40 -1-----­ (.) c: !IJ -.!!? 30 I/) Q) e:::: ~ 0 20 10 0 Cl Health Services Authority Pathology Laboratory Antibiotic Resistance E.coli (Jan 2012 - Dec 2016) Antibiotics a 2013 0 2014 • 2015 • 2016 5. Photo of Antimicrobial Resistance National Action Plan Development Working Group for the Cayman Islands L-R: Dale Chin, Microbiologist; Dana Scott, Infection Control Officer; Hazel Gordon-Fletcher, Infection Control Coordinator; Samantha Conolly, Pharmacist; Timothy Mclaughlin-Munroe, Public Health Surveillance Officer/Deputy National Epidemiologist; Dr. Samantha Dorman, Veterinary Officer Department of Agriculture; Dr. Samuel Williams-Rodriquez, Medical Officer of Health. Not pictured: Dr. Eryka Simmons, Genera l Practitioner; Antoinette Johnson, Laboratory Manager Department of Environmental Health; Colin Medford, Chief Pharmacist; Sarah Hetley-Frederick, Executive Secretary Public Health; Saleicia Samaroo, Public Health Intern