Sierra Leone National Strategic Plan for Combating Antimicrobial Resistance 2018-2022

GOVERMENT OF SIERRA LEONE NATIONAL STRATEGIC PLAN FOR COMBATING ANTIMICROBIAL RESISTANCE 2018-2022 1 TABLE OF CONTENTS ABBREVIATIONS AND ACRONYMS ................................................................................................. 2 FOREWORD ..................................................................................................................................... 3 PREAMBLE ON BEHALF OF THE MOHS, MAFFS AND EPA ............................................................. 4 ACKNOWLEDGEMENTS .................................................................................................................. 5 EXECUTIVE SUMMARY .................................................................................................................... 7 1. INTRODUCTION ....................................................................................................................... 9 2. SUMMARY OF PRELIMINARY SITUATIONAL ANALYSIS ........................................................ 11 1. Awareness and education ..................................................................................................... 11 2. Laboratory and surveillance ................................................................................................. 11 3. Infection prevention and control (IPC) ................................................................................. 12 4. Antimicrobial use ................................................................................................................ 12 3. NATIONAL STRATEGIC PLAN ................................................................................................. 13 1. Vision ................................................................................................................................... 13 2. Mission ................................................................................................................................. 13 3. Goal ...................................................................................................................................... 13 4. Objectives ............................................................................................................................ 13 5. Guiding Principles ................................................................................................................. 13 6. Strategies ............................................................................................................................ 14 7. Strategic Objectives .............................................................................................................15 4. OPERATIONAL FRAMEWORK FOR STRATEGIC OBJECTIVES ............................................... 27 5. MONITORING AND EVALUATION PLAN................................................................................ 44 6. REFERENCES .......................................................................................................................... 63 2 ABBREVIATIONS AND ACRONYMS AMR Antimicrobial resistance AMS Antimicrobial Stewardship AST Antibiotic sensitivity testing CIA Critically Important Antimicrobials CPG Clinical Practice Guidelines DRI Drug-Resistance Infections DTC Drugs and Therapeutics Committee EIA Environmental Impact Assessment EML Essential Medicines List EPA Environment Protection Agency FAO Food and Agricultural Organisation GAP Global Action Plan GHSA Global Health Security Agenda GLASS Global Antimicrobial Resistance Surveillance System HCAI Health care-associated infections IHR International Health regulation IPC Infection Prevention and Control JEE Joint External Evaluation MAFFS Ministry of Agriculture Forestry and Food Security MDR Multi-drug resistant MOHS Ministry of Health and Sanitation NMCG National Multi-Sectoral Coordinating Group PBSL Pharmacy Board of Sierra Leone WHA World Health Assembly WHO World Health Organisation 3 FOREWORD Antimicrobial resistance (AMR) threatens the effective prevention and treatment of infectious diseases by reducing the effectiveness of antimicrobial medicines. The impact on health and well being are longer duration of illness, longer treatment, higher mortality, treatment with expensive medicines, increased burden on health system and huge economic consequences. Safe, good quality and effective antimicrobial medicines are required for protecting patients from potentially fatal diseases and ensuring that intricate procedures, such as surgery and chemotherapy, can be provided at low risk. The development and implementation of a national strategic plan is required to curb the emergence and spread of AMR and this should also take into consideration collection of accurate information and strong inter-sectoral collaboration. In recognition of the urgency of combating AMR in Sierra Leone, the Ministries of Health and Sanitation (MOHS), Agriculture, Forestry and Food Security (MAFFS) and the Environment Protection Agency (EPA) put in place an inter-sectoral AMR Working Group in 2017. The MOHS, MAFFS, EPA and partners conducted a preliminary country situational analysis on AMR in 2017. The situational analysis preliminary findings recognised various issues that may contribute to AMR in Sierra Leone, including the absence of a comprehensive national policy and national strategic plan to combat AMR. To address these deficiencies, the findings from the situation analysis were used to develop the AMR strategic plan. This strategic plan underscores the need for an effective “one health” approach involving coordination among numerous sectors and partners, including human and veterinary medicine, agriculture and the environment. This national AMR strategic plan will enable the Government of Sierra Leone to curb antimicrobial resistance and improve patient outcomes. Signed by d by Signed by Dr. Abu Bakarr Fofanah Professor Patrick Monty Jones Mrs Haddijatou Jalloh Minister of Health and Sanitation Minister of Agriculture, Forestry Exe.Chairperson, and Food Security Environmental Protection Agency 4 PREAMBLE ON BEHALF OF THE MOHS, MAFFS AND EPA Antimicrobials have been valuable in fighting organisms causing infectious diseases in Sierra Leone for decades, but because of the irrational use of these medicines, an increasing number of these organisms may have developed resistance to them. From a global perspective, the problem was controllable as the growth of resistance was slow and the pharmaceutical industry continued to create novel antimicrobials. Over the past years, this problem has become a global concern since the development of antimicrobial resistance is happening at an alarming rate and is outdoing the development of new antimicrobials capable of fighting infections in humans and animals. Sierra Leone like other low-income countries, may already be encountering the challenges of AMR. It is an emerging national health concern which calls for an imperative inter-sectoral collaboration to proffer solutions that will address this looming threat. Therefore, Ministry of Health and Sanitation, together with the Ministry of Agriculture, Forestry and Food Security and the Environment Protection Agency and other stakeholders and international partners, led the development of the Sierra Leone National Strategic Plan on AMR based on the objectives of the global action plan (GAP) developed by the World Health Organisation and also the Food and Agricultural Organisation action plan on AMR (2016-2020). The congregation of the aforementioned Ministries, stakeholders and partners to develop this plan is a testament of their support to translated this plan into action. This is a multidimensional and all-inclusive strategy based on the “one health approach” which aims to consolidate all efforts in the fight against AMR in the country through this platform. If we want to avoid a post antibiotic era, we need to change our approach with respect to the way we handle antimicrobial agents. Action is needed now to prevent and control the spread of antibiotic resistance. This is an achievable venture and we charge all of us to participate in combating AMR in Sierra Leone. Signed by Signed by Dr. Brima Kargbo Mr. Francis A.R. Sankoh Chief Medical Officer Chief Agricultural Officer Ministry of Health and Sanitation Ministry of Agriculture, Forestry and Food Security 5 ACKNOWLEDGEMENTS Thanks to the following Ministries, Departments and Agencies, relevant stakeholders and international partners who attended the various AMR consultative meetings and gave comments and provided invaluable assistance on the various drafts of the Sierra Leone National Strategic Plan on Antimicrobial Resistance. Your support is gratefully recognised: Dr. Brima Kargbo, Chief Medical Officer, Ministry of Health and Sanitation (MOHS) Rev. Mrs. Lydia Sesay - Ministry of Agriculture, Forestry and Food Security (MAFFS) Dr Sahr R. Gborie, Ministry of Agriculture, Forestry and Food Security (MAFFS) Ms. Lovetta Juanah, Environment Protection Agency-SL Mr. Bashiru Kargbo, Environment Protection Agency-SL Dr. Victor E. Matt-Lebbie - Directorate of Hospital and Laboratory Services, MOHS Mrs. Nanah Sesay- Kamara - Infection and Prevention Control Unit (IPC), MOHS Mr. Roland Conteh - Disease Surveillance Programme, MOHS Mr. Abdul Rahman Conteh - Ministry of Agriculture, Forestry and Food Security (MAFFS) Ms. Dorcas W. Wanjolu - Ministry of Health and Sanitation / World Bank Dr. Amara Leno - Ministry of Agriculture, Forestry and Food Security (MAFFS) Pharm Bassie S. R. Turay, Directorator of Drugs and Medical Supplies, MOHS Pharm Fawzi Thomas, Directorate of Drugs and Medical Supplies, MOHS Pharm Jennet Buck, Directorate of Drugs and Medical Supplies, MOHS Pharm Ottis Williams, Directorate of Drugs and Medical Supplies, MOHS Pharm Ibrahim Gassama - Directorate of Drugs and Medical Supplies, MOHS Mrs. Doris Harding - Directorate of Hospital and Laboratory Services, MOHS Mrs. Christiana Kallon - Infection Prevention and Control Unit (IPC), MOHS Mr. Francis Koroma - Environmental Health Department, MOHS Mr. Lansana Conteh - Health Education Department, MOHS Mr. Gabriel Daniels- Management Sciences for Health (MSH) Alhaji Pharm Murtada Sesay - Management Sciences for Health (MSH) Pharm Mbalia Conteh - Management Sciences for Health (MSH) Dr. Mohan Joshi - Management Sciences for Health (MSH) Dr Ekaete Tobin, World Health Organisation (WHO) 6 Dr Anna Maruta, World Health Organisation (WHO) Dr Harry Opata, World Health Organisation (WHO) Mrs. Lizzie Sithole Buyiswa - World Health Organisation (WHO) Mr. Jonathan Greene - World Health Organisation (WHO) Dr. Fenella Beynon - King’s Sierra Leone Partnership Dr. Imogen Clarke - King’s Sierra Leone Partnership Pharm Mukeh Fahnbulleh - Development Alternatives Incorporated (DAI) Dr. Joshua Kimutai - Food and Agricultural Organisation (FAO) Dr. Gatechew Abebe - Food and Agricultural Organisation (FAO) Dr. Marcus Eder - Public health England (PHE) Dr. Bridgette Gleason, United States Centre for Disease Control and Prevention Mr. Mohamed B. Jalloh - Disease Prevention and Control (DPC) Pharm. Dr. Wiltshire C. N. Johnson, Registrar, Pharmacy Board of Sierra Leone Pharm. Onome Thomas Abiri – Pharmacy Board of Sierra Leone Pharm. Dr. Joseph Sam Kanu—Pharmacy Board of Sierra Leone Pharm. Mohamed sesay – Pharmacy Board of Sierra Leone Pharm. Sitta Kamara – Pharmacy Board of Sierra Leone Pharm. Abdulai Kanu-Pharmacy Board of Sierra Leone Pharm. Joy Johnson – Pharmacy Board of Sierra Leone Pharm. Sahr E. Gbomor – Pharmacy Board of Sierra Leone Pharm. Emmanuel K. Margao – Pharmacy Board of Sierra Leone Pharm. Umu Jalloh – Pharmacy Board of Sierra Leone Ms. Alison French – Pharmacy Board of Sierra Leone Mr. Alimamy Conteh – Pharmacy Board of Sierra Leone This strategic plan was derived from interactive discussions during the various consultative meetings. 7 EXECUTIVE SUMMARY Antimicrobials have been a critical public health tool since the discovery of penicillin in 1928, saving the lives of millions of people around the world. Today, however, the emergence of drug resistance is reversing the miracles of the past eighty years, with drug choices for the treatment of many infections becoming increasingly limited, expensive, and, in some cases, non-existent. Conscious of the public health threats of AMR to both humans, animals and the environment, the ministries of health and sanitation, agriculture forestry and food security and the environmental protection agency put together a national multi-sectoral coordinating group tasked with the responsibility of establishing mechanisms to integrate all initiatives into a single concerted action and development of the national AMR strategic plan (2018-2022). The National Strategic Plan on Antimicrobial Resistance is the first approach which addresses AMR specifically. The drafting process began in the February, 2017 with full involvement of multi stakeholders. The draft versions have gone through several rounds of consultations. Through these processes, the draft plan was finalized in October, 2017 endorsed by the ministers of health and sanitation, agriculture forestry and food security and the executive chairperson of the environment protection agency. The plan is guided by the ‘One Health’ approach which recognizes the interconnectivity across human, animal and environmental health. The objectives of the national strategic plan include: 1. To establish an AMR governance structure 2. To improve AMR awareness and education 3. To strengthen Laboratory and Surveillance 4. To reduce incidence of infection through IPC 5. To optimize antimicrobial use in all sectors 6. Ensure sustainable investment through research and development. Although the primary purpose of the plan is to provide direction for the activities of Government, the national strategic plan is also intended to guide action by the human, animal and environmental sectors and partners in a common effort to address urgent and serious drug-resistant threats that affect the population of Sierra Leone. This will also promote Government’s effort in support of the World Health Assembly resolution 67.25 (Antimicrobial Resistance), which urges countries to take urgent action at the national, regional, and local levels to combat resistance. The strategic plan will also result in improved antibiotic stewardship in healthcare settings, prevention of the spread of drug-resistant threats, elimination of the use of medically important antibiotics for growth promotion in food animals, and expanded surveillance for drug-resistant infections in humans and animals. Other significant outcomes include creation of an AMR reference public health laboratory, establishment of a AMR database that can be accessed by government, industrial and academic researchers. 8 Implementation of the objectives and activities in the plan requires continued, synchronised, and complementary efforts of government and partners, including healthcare professionals, healthcare leaders, veterinarians, agriculture industry leaders, environmentalists, manufacturers, policymakers, and patients. All of us who depend on antimicrobials must join in a common effort to detect, stop, and prevent the emergence and spread of resistant infections. 9 1. INTRODUCTION Since the discovery of penicillin by Sir Alexander Fleming in 1928, antimicrobial drugs have led to significant advancement in medicine and surgery, saved millions of lives all across the world, substantially reduced the burden of diseases, improved the quality of life and increased life expectancy. In recent years the emergence and spread of antimicrobial resistance (AMR) in several microorganisms has rendered the management of many infectious diseases difficult. The development of resistance to drugs commonly used to treat malaria, TB and HIV is of particular concern and an impediment in achieving the Sustainable Development Goals of 2021. AMR is the ability of an organism to 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”. Resistant microorganisms (including bacteria, fungi, viruses and parasites) are able to withstand attack by antimicrobial drugs, such as antibiotics, antifungals, antivirals, and anti-parasitics. The standard treatments become ineffective and infections persist, increasing the risk of spread to others. Antimicrobial resistance is a natural biological phenomenon that is accelerated by a variety of factors, one of which is human practices. The use of an antimicrobial for any infection in any dose and over any time period, forces microbes to either adapt or die in a phenomenon known as "selective pressure". The microbes which adapt and survive carry genes for resistance, which can be passed on. When antimicrobials are used incorrectly: for too short a time, at too low a dose, or for the wrong disease; the likelihood that bacteria and other microbes will adapt and replicate rather than be killed is greatly enhanced. Much evidence supports the view that the total consumption of antimicrobials is a critical factor in the development of AMR. Paradoxically, under use through lack of access, inadequate dosing, poor adherence, and substandard antimicrobials may play as important a role as overuse. Its Emergence is a result of the use, overuse and misuse both in humans and animals. AMR has multiple implications not only for the patients and family, but also on more broadly terms, the health system of any country. As microbes become more resistant to common, inexpensive antimicrobials, there is a tendency to move on to more expensive and often multidrug treatment including the use of second or third line antimicrobial agents, increasing the cost of health care. AMR thus diminishes the therapeutic choices available to patients and healthcare providers. Other 10 untoward effects of AMR include increased mortality rates, long hospital stays, admission to the intensive unit and the spread of resistant microorganism to other patients. The containment and prevention of antimicrobial resistance is a biological, behavioral, technical, economic, regulatory and educational problem, and requires a comprehensive, integrated well coordinated response employing evidence based strategies, with active support and participation from national level. In addressing AMR, the Government of Sierra Leone adopted the Agenda of the Sixty-eighth (68 th ) World Health Assembly (WHA) of May 2015, where the global action plan on antimicrobial resistance was adopted and Member States urged to develop National Action Plans (NAP) for AMR using a “One Health Approach”. The NAP will outline the key strategic objectives, interventions and activities to slow the development and spread of AMR and improve patient outcome. The NAP provides a structure for a coordinated response to strengthening national stewardship among the numerous sectors and actors, including human, animal, agriculture, finance and the environment. 11 2. SUMMARY OF PRELIMINARY SITUATIONAL ANALYSIS A preliminary country situational analysis was conducted in 2017 led by an informal AMR National Multi-Sectoral Coordinating Group (NMCG) with focal points for human, environment and animal health, to provide baseline information on the status of AMR in Sierra Leone and to identify gaps and challenges in curbing AMR. The situational analysis was drawn out of a literature review of published and unpublished data as well as interviews of key informant across relevant sectors. Information was also collected from the 2016 joint external evaluation report for Sierra Leone. The findings of the situational analysis informed the development of the NAP, and are summarized below: 1. Awareness and education  No public awareness on AMR  Non-inclusion of AMR in pre-service or in-service programmes for professionals in the veterinary, human health, agriculture sectors.  Civil society groups, faith-based organizations, Non-governmental organizations (NGO) or other consumer or professional groups rarely involved with AMR activities.  AMR not included in primary or secondary school curricula.  No commemoration of the WHO antibiotic awareness week or any other world/regional AMR awareness campaign. 2. Laboratory and surveillance  No national plan for detection and reporting of priority antimicrobial resistant pathogens as stipulated by WHO.  No laboratory has been formally designated as AMR laboratory.  The National Health Laboratory Strategic Plan (2016–2020) does not address antimicrobial resistance.  Information on resistance patterns to common bacteria is available in a few private clinical laboratories, where drug susceptibility testing is provided on request such as when patients fail to respond to treatment. In such instances, epidemiological data is not mandatorily collected.  Capacity for bacteriological culture and antimicrobial susceptibility testing (AST) is limited by lack of skilled laboratory personnel, limited supply of reagents and a weak supply chain system for laboratory commodities, lack of equipment and standard operating procedures.  There is limited participation in internal or external quality assurance program for microbiology, being limited to only the Central reference laboratory and Connaught hospital.  Disease specific surveillance systems exist for malaria and HIV, but as in the case of malaria, are not linked to entomological data from the vectors. 12  Monitoring of use of antimicrobial agents in humans, animals and plants is not undertaken.  No centre responsible for coordination of surveillance activities for AMR.  Few published studies on antimicrobial use. 3. Infection prevention and control (IPC)  A national IPC policy and plan are available, with IPC SOPs, guidelines and protocols implemented in selected health facilities.  A national programme for Health care-associated infections (HCAI) surveillance is soon to be rolled out.  Trained IPC professionals are in all tertiary hospitals  IPC committees are present at tertiary hospitals and regional government owned health facilities.  IPC programs are non-existent in congregate settings (boarding homes and hostels, correctional facilities).  IPC and hygiene topics are not included as core components of pre-service education curricula for students in human health or veterinary programmes neither are they components of in service training for health, environment, agriculture or veterinary professionals.  There are no policies, guidelines or standards on pharmaceutical waste management.  No IPC programmes in agriculture and animal health. 4. Antimicrobial use  No national policy and regulation for antimicrobial stewardship, although essential treatment guidelines exist and are in use.  No national guidance on appropriate antimicrobial use in humans and animals.  Weak capacity for improving antibiotic prescribing and consumption in humans because antibiotics are available without prescription.  No guidance of antimicrobial use in animals and plants and no national guideline on monitoring and regulation of drug residues in animal products.  Inadequate monitoring of antibiotic consumption and use in human, environmental and animal health sectors.  No Drugs and Therapeutics Committee (DTC) carrying out AMR related activities 13 3. NATIONAL STRATEGIC PLAN 1. Vision A society where antimicrobials are handled as a valuable asset for present and future generations in the treatment of infections in humans, animals, environment and the agricultural sector. 2. Mission To effectively combat the development and spread of antimicrobial resistance in Sierra Leone so that it no longer constitutes a public health threat, using a one health approach that integrates infection prevention and control, rational use of antimicrobials, availability of safe and effective antimicrobials of good quality, diagnostic stewardship and surveillance. 3. Goal The overarching goal of the NAP is to ensure, for as long as possible in Sierra Leone, continuity of successful treatment and prevention of infectious diseases with medicines that are quality-assured, prescribed and used responsibly, and accessible to all who need them at a price that they can afford. 4. Objectives The following are the specific objectives of the NAP-: 1. Define the strategic priorities, key actions, responsibilities, timelines and budget for AMR activities, define and strengthen organizational & management structures for intra- and inter sectoral coordination within a One Health approach; 2. Achieve better understanding and awareness of AMR, strengthened surveillance, prevention of emergence and spread of resistant microbes through infection prevention and control, optimized use of antibiotics in all sectors, and enhanced investments for AMR activities, communications, research and innovations. 3. Improve international collaboration and capacities for antimicrobial resistance prevention, surveillance, control and antibiotic research and development. 4. Enable monitoring and evaluation (M&E) of the NAP implementation. 5. Guiding Principles The guiding principles as outlined in the GAP and the resolution of the WHA describes the common approach for all stakeholders at the national, institutional, and individual levels. Such actions are linked to regional and global efforts. 14 The principles are as follows: i. Whole-of-society engagement Antimicrobial resistance affects human health, animal health, agriculture, food security, water and sanitation and economic development. Therefore, all sectors and disciplines should be actively engaged in the fight against AMR. ii. Prevention first Prevention of infection in the first instance is cost effective and can be implemented in all settings. Good sanitation, hygiene and other infection prevention measures that can slow the development and restrict the spread of difficult-to-treat antibiotic-resistant infections are key to combatting AMR. iii. Access Successful implementation of NAP depends on access and appropriate use of existing and new antimicrobial medicines, health facilities, health care professionals, veterinarians, preventive technologies and diagnostic tools, education and information. iv. Sustainability The implementation of the NAP requires long-term investment in all the strategies in the plan. Political commitment and international collaboration are needed to promote the technical and financial investment necessary for effective development and implementation. v. Incremental targets for implementation That NAP offers an opportunity for the country to determine the priority actions that it needs to take to attain each strategic objective in a stepwise manner that meets both local needs and global priorities. 6. Strategies The NAP articulates the priorities and interventions to be implemented between 2018–2022. The focus areas of the NAP are: 1. Establish a governance structure for the implementation of the AMR strategic plan 2. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. 3. Strengthen the knowledge and evidence base through laboratory, surveillance and research 15 4. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures 5. Optimize the use of antimicrobial agents in human, animal and plant health 6. Develop the economic case for sustainable investment and actions to combat AMR 7. Strategic Objectives Strategic Objective 1: Establish a governance structure for the implementation of the NAP Concerted and nationally coordinated efforts are needed to bring together various stakeholders under the umbrella of one health to harness their expertise and resources under a strong political leadership. Priority action 1: Governance Objective 1: Establish an AMR governance structure at national level Interventions Activities 1.1 Establish AMR national multi sectoral coordinating group (NMCG) 1.1.1 Define membership to be representative of all stakeholders and appoint persons into the NMCG 1.1.2 Develop and approve TOR 1.1.3 Designate national focal persons for AMR in the health, animal and environmental sectors 1.1.4 Establish a secretariat for the NMCG 1.1.5 Organise quarterly meetings to review progress towards implementation of NAP 1.2 Include AMR into the existing ‘one health structure’ 1.2.1 Expand terms of reference (TOR) of National one health committee to include AMR 1.3 Develop an implementation plan for the AMR strategic plan 1.3.1 Develop a roadmap for the implementation of the AMR strategic plan 1.3.2 Cost the AMR strategic plan Strategic Objective 2: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. Urgent steps are required to raise awareness on AMR and promote behavioural change, through public communication programmes for audiences in human, environmental, animal and plant health. Inclusion of the AMR and related topics in primary and secondary school curricula will 16 promote understanding and awareness from an early age, likewise making AMR a core component of professional education, training, certification, continuing education and development in the health, veterinary sectors and agricultural practice, will promote understanding and awareness among professionals. The priority actions in this strategic objective are as follows: • Awareness-raising and risk communication • Education Priority action 2: Awareness raising and risk communication Objective 2: Increase awareness on AMR Interventions Activities 2.1 Establish evidence based public communication programmes targeting audiences in the human, animal health and crop production sectors 2.1.1. Estimate awareness and knowledge through knowledge, attitude, practice and behavioural studies in the general populace and professional groups- human health, veterinary, farmers and food processing sector 2.1.2 Develop and disseminate national communication strategy for AMR 2.2. Develop communication strategies, messages and materials to promote AMR awareness 2.2.1 Carry out advocacy and sensitization meetings for parliamentarians, local government, chiefdom chiefs, at national, district and chiefdom levels 2.2.2 Develop and disseminate communication messages in the print and broadcast media and IEC materials (including billboards, posters, radio spots) to guide health workers, pharmacists communities on prevention of drug resistance 2.2.3 Engage non-governmental organizations, Civil Society Organizations and the media to deliver messages on AMR 2.2.4 Commemorate Antibiotic awareness week 2.3 Awareness on AMR is improved among food and agriculture stakeholders 2.3.1 Develop communication, advocacy products and evidence-based messaging that targets different sectors of agriculture in order to: • ensure the required understanding of the challenges and risks AMR, • safe farming practices that enable decreased use of antibiotics and antimicrobials in livestock production, • outcomes of irresponsible use of antibiotics and antimicrobials, & • detrimental effects of antibiotics in the environment, 17 Priority action 3: Education Objective 3: Improve knowledge of AMR Interventions Activities 3.1 Include AMR and related topics in school curricula across all levels of education 3.1.1. Develop modules on AMR and related topics in primary, secondary and tertiary education curricula 3.2 Include AMR continuing professional education (CPE) programmes for professionals 3.2.1 Engage professional registration boards for inclusion of AMR CPE as pre-requisite for licence renewal 3.2.2 Conduct Annual scientific symposium on AMR for human, animal and veterinary professionals 3.3 Develop and implement in service training programs on AMR for professionals in the human health, veterinary, environmental and agricultural sectors 3.3.1 Engage stakeholder in the educational sector in a consultative meeting to develop curriculum for AMR 3.3.2 Train professionals, through short courses, in-service and pre-service programmes in the human health, veterinary, food production and agriculture sectors on AMR Strategic Objective 3: strengthen the knowledge and evidence base through laboratory, surveillance and research Surveillance of antimicrobial resistance is critical for providing data on the extent and trends of the AMR problem. Through the NAP, the national surveillance system for AMR will be established. Laboratory-based surveillance is required for national action in the monitoring of AMR and its spread. For reliable microbiological and antimicrobial susceptibility testing, it is imperative to equip laboratories with equipment, reagents and human resource. Furthermore, a coordinated mechanism for AMR reporting will be established in order to share information employing the one health approach. Surveillance of antimicrobial consumption is an important aspect in combating AMR, and will be undertaken in humans, animals, plants and environment. The interventions under surveillance and research include the following priority actions:  Laboratory capacity  Surveillance  Research and development 18 Priority action 4: Laboratory capacity Objective 4: Build laboratory capacity to produce high-quality microbiological data for patient management and support surveillance activities in the human, veterinary, animal and environmental sectors. Interventions Activities 4.1 Strengthen laboratory capacity to monitor AMR at national and regional level in the human health sector 4.1.1 Designate a national laboratory for AMR surveillance with clearly articulated TOR 4.1.2 Appoint a focal person for AMR surveillance in the national AMR laboratory with defined roles and responsibilities 4.1.3 Standardize SOPs for laboratory testing for AMR 4.1.4. Conduct training, competency and external proficiency program for all sites in the surveillance network conducting Antibiotic sensitivity testing (AST) for sentinel sites. 4.1.5 Identify, designate and support regional laboratories for AMR sentinel surveillance 4.1.6 Standardize AMR reporting system across laboratories 4.1.7 Enrol national and regional laboratories in external quality assurance schemes, monitor and evaluate their performance, and implement corrective actions. 4.1.8 Enrol national and regional laboratories in GLASS 4.1.9 Support an uninterrupted supply of quality laboratory reagents and supplies. 4.1.10 Conduct molecular characterization of any resistance determinants from Multi-drug resistance (MDR) organisms 4.1.1 Establish Repository of MDR isolates 4.2 Strengthen laboratory and diagnostic capacity to monitor AMR and antimicrobial residue at national and regional level in the animal health and agricultural sector 4.2.1 Assess existing capacities for monitoring AMR and detecting antimicrobial residues; 4.2.2 Establish laboratory capacity for screening of antibiotic residues in food products locally produced or imported and AMR in pathogens isolated from food products. 4.2.3 Establish AMR laboratory capacity to conduct antibiotic surveillance in pathogens isolated from food-producing animals 4.2.4 Strengthen national laboratory capacity to monitor AMR and detect antimicrobial residues in food products and the environment; 4.2.5 Training of lab personnel to make analyses – microbiological and physiochemical testing of animals and 19 animal products; 4.2.6 Field testing of antibiotics for active ingredients. 4.3 Strengthen laboratory capacity to monitor AMR at national and regional level in the environment sector. 4.3.1 Develop a laboratory capacity to analyzed water and Soil samples for possible AM residue 4.3.2 Capacity building via training of EPA-SL to analyze potential AM contaminated samples. 4.3.3 Conduct an inventory aimed at identifying AMR contaminated site in country. 4.4 Develop a Geographic Information System (GIS) Map indicating contaminated and sampling sites in Sierra Leone. 4.4.1 Establish a monitoring and surveillance plan 4.4.2 Establish an electronic database to assess trend. Priority action 5: Surveillance systems Objective 5: Set-up a national antimicrobial resistance surveillance system Interventions Activities 5.1 Establish an integrated AMR surveillance system 5.1.1 Establish coordinating centre for AMR to systematically collect, analyse and report antimicrobial use and resistance 5.1.2 Develop an AMR one health surveillance plan through the establishment a surveillance technical group with an endorsed TOR to develop the One Health surveillance system to include routine, sentinel and surveys 5.1.3Develop forms, tracking software and reports on the use of antibiotics and drug resistance 5.1.4 Organize regular review meetings among relevant groups of stakeholders to review data on both antimicrobial use and resistance, and take practical steps to translate those data into actions, such as informing new or revision of policies and practice guidelines 5.1.5 Establish a mandatory requirement for submission of all AMR data including i.e. from vertical programmes, animal health and food safety in the public, NGO, and private sectors 5.2 Establish antimicrobial use surveillance in animal health and agriculture sectors 5.2.1 Develop plans to monitor antimicrobial use in animals and crop production 5.2.2 Conduct antimicrobial use surveys/studies at national, district and community level, and also in veterinary and agricultural settings 5.2.3 Strengthen mechanisms to check for levels of antimicrobial agents in imported as well as locally produced animal and plant food products, and also levels of antimicrobial discharge in the environment such as waterways. 5.2.4 Establish systems to collect data on national level sales or consumption of antibiotics, prescribing practices and appropriate antibiotic use at selected health care settings, 20 5.3 Establish AMR surveillance in environmental sector 5.3.1 Identify and implement ‘clean up’ of AMR Contaminated sites 5.3.2 Incorporate the concept of AMR into the waste managment policies of companies and Industries 5.3.3 Strengthen mechanisms to check for levels of antimicrobial discharge in the environment such as waterways 5.3.4 Incorporate AMR Concept into the Terms and Conditions of EIA Licenced Holders. 5.3.5 Develop and popularise guidelines on the safe disposal of AMR products at industries and health facilities 5.4 Improve information dissemination for antimicrobial surveillance and antimicrobial use 5.4.1 Disseminate monthly AMR reports to the antimicrobial stewardship committee in healthcare facilities 5.4.2 Disseminate quarterly AMR reports among facility health providers and DHMTs to increase awareness of AMR profiles among circulating pathogens 5.4.3 Provide annual AMR surveillance reports to committees responsible for revising standard treatment guidelines, Clinical Practice Guidelines (CPGs), Essential Medicines List (EML), and Infection Prevention and Control (IPC) guidelines. Priority action 6: Research and development Objective 6: Identify operational research priorities in human, environmental and animal health Interventions Activities 6.1 Develop a national research agenda on AMR 6.1.1 Engage relevant experts to identify current gaps in knowledge and potential research topics. 6.1.2 Develop research guidelines on AMR 6.1.3 Undertake research on AMR 6.2 Establish a system for sharing data on AMR research 6.2.1 Organize multisector national AMR scientific symposiums 6.2.2 Establish a national AMR data repository 21 Strategic Objective 4: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention control (IPC) measures Better hygiene and infection prevention measures are essential to limit the development and spread of antimicrobial resistant infection and multi-drug resistant pathogens. Drug resistant does not only occur in health care setting but also at the household level. IPC with proper training of health personnel and education in the community level is needed to combat AMR. To facilitate IPC in health care, there is a need to strengthen the national infection prevention and control programme at all levels. The use of vaccines can reduce the infection rates and dependency on antimicrobial agents as well as the risk that antimicrobial resistant pathogens will develop and spread through food chain. Four priority areas are identified:  Infection prevention and control in health care  Infection prevention in animal health  Hygiene, sanitation and infection prevention in the community  Health care waste management Priority action 7: Infection prevention and control in human health Objective 7: Strengthen the national infection prevention programme for human health Interventions Activities 7.1 improve sensitization and monitoring of IPC practices 7.1.1 Carry out awareness meetings on hand hygiene and prevention of healthcare-associated infections at training institutions, health facilities, and veterinary services 7.1.2 Conduct Hand hygiene audits 7.1.3 Strengthen IPC measures in human health facilities, including long-term care and congregate settings 7.1.4 Upgrade training curriculum for IPC training to include AMR 7.1.5 Education and training of healthcare workers on AMR 7.1.6 Establish HAI surveillance programmes 7.1.7 Conduct supervision of IPC implementation 7.1.8 Monitor implementation of IPC quarterly with timely feedback. 22 Priority action 8: Infection prevention in animal health and agriculture Objective 8: Introduce infection prevention and control programmes in agricultural settings and animal husbandry. Interventions Activities 8.1 Include hygiene and infection prevention and control as core (mandatory) content in training and education of veterinary professionals. 8.1.1 Include hygiene and infection prevention and control in undergraduate curricula for animal health professionals. 8.2 Implement IPC programmes across the agricultural and fisheries sectors 8.2.1 Establish IPC programmes in animal health, agriculture and fisheries, including health inspections of abattoirs, farms and communities, and monitor and improve adherence to national/facility IPC policies and standards Priority action 9: Hygiene, sanitation and infection prevention in the Community Objective 9: Limit the development and spread of AMR in the community by infection prevention and control measures Interventions Activities 9.1 Promote personal hygiene by social mobilization and behavioural change activities. 9.1.1 Estimate knowledge of personal hygiene in different social groups as a basis for the social mobilization campaigns. 9.1.2 Promote hygiene, sanitation and other behaviours that contribute to infection prevention in the community 9.2 Encourage continued increases in vaccination rates at veterinary and human health facilities to prevent infection 9.2.1 Promote vaccination amongst veterinary, human health workers and the general public. Priority action 10: Waste management Objective 10: Strengthen waste management in all sectors Interventions Activities 10.1 Reduce environmental contamination with resistant pathogens and antimicrobial residues 10.1.1 Develop systems for safe collection, transport and disposal of waste from human health, animal and agricultural facilities through the establishment an effective waste management system, specifically addressing water sewage and landfills (solid waste) involving agricultural, medical and pharmaceutical waste 10.1.2: Establish national and sub-national monitoring system for waste management 23 Strategic Objective 5: Optimize the use of antimicrobial agents in human, animal and plant health Indiscriminate use of antimicrobials gives rise to development of antimicrobial resistance. The indiscriminate use may be on human health or in animal husbandry. Therefore, rational use of antimicrobials in human as well as in animal health is of utmost importance to reduce development of resistance to antimicrobials thus the need for developing antimicrobial stewardship programmes. Antimicrobial stewardship includes not only limiting inappropriate use but also optimizing antimicrobial selection, dosing, route, and duration of therapy to maximize clinical cure or prevention of infection, while limiting the unintended consequences. The judicious use of antimicrobials (AMs) in both human and veterinary settings is an important strategy to reduce the possibility of emergence of resistance. Overuse and misuse resulting from poor prescribing and dispensing behaviour, uninformed patient demand and lack of adherence to treatment regimen prescribed, low-quality drug formulations, inadequate dosage regimens, and insufficient duration of therapy are also important contributors to AMR Three specific objectives are defined under this strategic objective:  Regulated access  Antimicrobial stewardship  Antimicrobial use in human and animal health Priority action 11: Regulated access to high quality antimicrobials Objective 11: Ensure uninterrupted access to high-quality antimicrobial medicines Interventions Activities 11.1 Improve access, strengthen regulation and supply chain management for antimicrobial agents. 11.1.1 Strengthen the quality management system for the supply of medicines, covering storage, transport, distribution and inventory management 11.1.2 Strengthen national mechanisms for registration of antimicrobial medicines through the Pharmacy Board of Sierra Leone(PBSL) 11.1.3 Conduct monitoring and post marketing surveillance of antimicrobials circulating in the market (public and private sectors) 11.1.4 Build capacity for effective and enforceable regulation of antimicrobial management, including quality assurance of all imported products including antimicrobials, reagents and pesticides and standardization of diagnostic equipment 24 11.1.5 Review and enforce use of a national and institutional essential medicine list guided by the WHO model list of essential medicines and national AMR data 11.1.6 Develop clinical practice guidelines such a national formulary, standard treatment guidelines with participation of relevant stakeholders 11.1.7 Provide appropriate training for personnel engaged in supply chain management and medicines regulation 11.1.8 Conduct audit inspections of pharmaceutical importers to check on the quantities of antimicrobial agents (for human and animal use) imported and distributed as well as the quantity remaining (if any) 11.1.9 Conduct follow - up audit inspections of medical prescriptions, prescription registers of community retail pharmacy outlets and government dispensaries to check whether antimicrobial agents were dispensed on prescription or not. 11.1.10 Development of antimicrobial prescription and utilization registers for deployment at public and private pharmacies and drugstores 11.1.11 Equip the national medicines quality control laboratory to perform quality assays and strengthen the national pharmacovigilance reporting systems 11.1.12. Develop guidelines related to the prescription, sales, dispensation, and administration of antimicrobials. Priority action 12: Antimicrobial stewardship (AMS) Objective 12: Improve and measure appropriate use of antimicrobial agents in health care Interventions Activities 12.1 Create formal AMS programmes in health care facilities 12.1.1 Develop policy and regulations for AMS 12.1.2 Establish AMS committees in health facilities 12.1.3 Develop a list of critical antibiotics to human health whose access should be controlled (e.g. Fluoroquinolones, third and fourth generation cephalosporins, carbapenems, amikacin, vancomycin). 12.1.4 Develop and implement national and facility-level antimicrobial stewardship programs, including medicine use reviews/evaluations, and implementation and monitoring of the use of STGs in both human and veterinary settings. 12.1.5 Promote and monitor the use of evidence-based rapid diagnostic tests to facilitate diagnosis and optimal antimicrobial treatment 25 12.1.6 Establish or strengthen capacity of existing drug and therapeutics committees (DTCs) in carrying out antimicrobial stewardship containment activities 12.1.7 Establish drug information centres (DICs) to provide information on antibiotic use and resistant Priority action 13: Antimicrobial use in animal health and agriculture Objective 13: Ensure prudent use of antimicrobial agents in terrestrial and aquatic animals and agriculture interventions Activities 13.1 Establish national policies on use of antimicrobial agents in animals, agriculture and fisheries. 13.1.1 Develop guidelines for the use of antimicrobials in food-producing animals based on the WHO list of Critically Important Antimicrobials(CIA) 13.1.2 Establish a strong regulatory framework for authorization and control of the quality of veterinary medicines. 13.1.3 Establish regulation for the restriction of non therapeutic use of antimicrobials (e.g. growth promoters) in food-producing animals and use of critically important antimicrobials for human medicine in food- producing animals. 13.1.4 Develop/review national medicines, pesticides and national livestock policy to address AMR Strategic Objective 6: Develop the economic case for sustainable investment and increase investment in new medicines, diagnostic tools, vaccines and other interventions Targeted and interdisciplinary research efforts are needed to fill gaps that still exist in understanding of prevalence of antimicrobial resistance, patterns and its epidemiological impact on human and animal pathogens and diseases. New medicines, diagnostic tools and vaccines are needed to combat emerging and spreading antimicrobial resistant pathogens. Studies are needed to determine the economical case for further investment in research for new drug discoveries, development and piloting of new diagnostic tools, vaccines and alternative interventions. To prepare the economic case for sustainable investment on AMR intervention, investment required will be identified, priorities on scientific research on AMR will be set and international collaboration will be fostered to support investigation and testing of new innovative technologies in the respective areas. 26 Priority action 14: sustainability of antimicrobial resistance interventions Objective 14: Prepare the economic case for sustainable investment and actions to fight AMR. interventions Activities 14.1. Prepare a plan to secure and use financing for implementation of the AMR strategic plan 14.1.1 Assess investment requirements for implementation of the strategic plan. 14.2 Strengthen partnership and governance to support and enhance AMR containment efforts 14.2.1 Build and expand local, national, regional and international partnerships and coalitions in support of AMR containment, including public-private partnerships 14.2.2 Strengthen AMR containment-related governance through a national multi-sectoral and multi-disciplinary coordinating team, and focal points at different levels with clearly defined terms of reference, mandates and accountability 14.3 Strengthen advocacy for funding and support for AMR containment 14.3.1 Advocate for budgetary funding for AMR containment efforts from government, donors, and the private sector 14.3.2 Include relevant AMR related activities into MoHS annual operational plan and MoHS strategy 14.3.3 Include relevant AMR related activities into MAFFS annual operational plan and MAFFS strategy 14.3.4 Include relevant AMR related activities into EPA annual operational plan and EPA strategy 14.4 Coordinate national research efforts and information sharing 14.4.1 Conduct research and promote information sharing with regard to various aspects of AMR containment including understanding and awareness of AMR, surveillance of antimicrobial use and resistance, infection prevention/control, optimized use of antimicrobials, and development and diffusion of new antimicrobials, vaccines, diagnostics, and novel delivery methods 14.4.2 Develop AMR research Agenda for human, animal and environmental health 14.4.3 Provide incentive and research funding for researches on AMR 27 4. OPERATIONAL FRAMEWORK FOR STRATEGIC OBJECTIVES The operational plan matrix consists of activities, key outputs, responsible institutions/ agencies and projected timeline for implementation. The AMR Plan will be reviewed every two years or more frequently if necessary. GLOBAL STRATEGIC OBJECTIVE 1. ESTABLISH A GOVERNANCE STRUCTURE FOR THE IMPLEMENTATION OF THE AMR STRATEGIC PLAN Objective 1: Establish an AMR governance structure at national levels Governance Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 1.1 Establish AMR national multi sectoral coordinating group (NMCG) 1.1.1 Define membership to be representative of all stakeholders and appoint persons into the NMCG MOHS, MAFFS, EPA 1.1.2 Develop and approve TOR AMR NMCG 1.1.3 Designate national focal persons for AMR in the health, animal and environmental sectors MOHS, MAFFS, EPA 1.1.4 Establish a secretariat for the NMCG MOHS, MAFFS, EPA 1.1.5 Organise quarterly meetings to review progress towards implementation of NAP AMR NMCG 1.2 Include AMR into the existing ‘one health structure’ 1.2.1 Expand terms of reference (TOR) of National one health committee to include AMR MOHS, MAFFS, EPA 1.3 Develop an implementation plan for the AMR strategic plan 1.3.1 Develop a roadmap for the implementation of the AMR strategic plan MOHS, MAFFS, EPA 1.3.2 Cost the AMR strategic plan MOHS, MAFFS, EPA 28 GLOBAL STRATEGIC OBJECTIVE 2: IMPROVE AWARENESS AND UNDERSTANDING OF ANTIMICROBIAL RESISTANCE THROUGH EFFECTIVE COMMUNICATION, EDUCATION AND TRAINING. Objective 2: Increase awareness on AMR Awareness and Risk communication Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 2.1 Establish evidence based public communication programmes targeting audiences in the human, animal health and crop production sectors 2.1.1. Estimate awareness and knowledge through knowledge, attitude, practice and behavioural studies in the general populace and professional groups- health, veterinary, farmers and food processing sector, pharmaceuticals. AMR NMCG, MOHS, MAFFS, Professional councils 2.1.2 Develop and disseminate national communication strategy for AMR AMR NMCG, MOHS, MAFFS, EPA 2.2 Develop communication strategies, messages and materials to promote AMR awareness 2.2.1 Carry out advocacy and sensitization meetings for parliamentarians, local government, chiefdom chiefs, at national, district and chiefdom levels AMR NMCG, MOHS, MAFFS, EPA 2.2.2 Develop and disseminate communication messages in the print and broadcast media and IEC materials (including posters, billboards, radio spots) to guide health workers, pharmacists, communities on prevention of drug resistance. AMR NMCG, MOHS, MAFFS, EPA 2.2.3 Engage non-governmental organizations, Civil Society Organizations and the media to deliver messages on AMR. AMR NMCG, MOHS, MAFFS, EPA 2.2.4 Commemorate Antibiotic awareness week AMR NMCG, MOHS, MAFFS, EPA, Media and partners 2.3 Awareness on AMR is improved among food and agriculture stakeholders 2.3.1 Develop communication, advocacy products and evidence-based messaging that targets different sectors of agriculture in order to: • ensure the required understanding of the MAFFS 29 challenges and risks AMR • safe farming practices that enable decreased use of antibiotics and antimicrobials in livestock production • outcomes of irresponsible use of antibiotics and antimicrobials • detrimental effects of antibiotics in the environment GLOBAL STRATEGIC OBJECTIVE 2: IMPROVE AWARENESS AND UNDERSTANDING OF ANTIMICROBIAL RESISTANCE THROUGH EFFECTIVE COMMUNICATION, EDUCATION AND TRAINING. Objective 3: Improve knowledge of AMR Education Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 3.1 Include AMR and related topics in school curricula across all levels of education 3.1.1. Develop modules on AMR and related topics in primary, secondary and tertiary education curricula MOH, MAFFS, EPA, MEST 3.2 Include AMR continuing professional education (CPE) programmes for professionals 3.2.1 Engage professional registration boards for inclusion of AMR CPE as pre-requisite for licence renewal MOHS, MAFFS, EPA, Professional councils 3.2.2 Conduct Annual scientific symposium on AMR for human, animal and veterinary professionals MOHS, MAFFS, EPA, Professional councils, Academic institutions 3.3 Develop and implement in service training programs on AMR for professionals in the human health, veterinary, environmental and agricultural sectors 3.3.1 Engage stakeholder in the educational sector in a consultative meeting to develop curriculum for AMR MEST, Academic institutions, AMR NMCG, MOHS, MAFFS, EPA 30 3.3.2 Train professionals, through short courses, in service and pre-service programmes in the human health, veterinary, food production and agriculture sectors on AMR MOHS, EPA, MAFFS GLOBAL STRATEGIC OBJECTIVE 3: STRENGTHEN THE KNOWLEDGE AND EVIDENCE BASE THROUGH LABORATORY, SURVEILLANCE AND RESEARCH Objective 4: Build laboratory capacity to produce high-quality microbiological data for patient management and support surveillance activities in both human and animal sectors. Laboratory capacity Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 4.1 Strengthen laboratory capacity to monitor AMR at national and regional level in the human health sector 4.1.1 Designate a national laboratory for AMR surveillance with clearly articulated TOR MOHS, 4.1.2 Appoint a focal person for AMR surveillance in the national AMR laboratory with defined roles and responsibilities MOHS, 4.1.3 Standardize SOPs for laboratory testing for AMR MOHS, 4.1.4. Conduct training, competency and external proficiency program for all sites in the surveillance network conducting Antibiotic sensitivity testing (AST) for sentinel sites. MOHS, 4.1.5 Identify, designate and support regional MOHS, 31 laboratories for AMR sentinel surveillance 4.1.6 Standardize AMR reporting system across laboratories MOHS, 4.1.7 Enrol national and regional laboratories in external quality assurance schemes, monitor and evaluate their performance, and implement corrective actions. MOHS, 4.1.8 Enrol national and regional laboratories in Global Antimicrobial Resistance Surveillance System (GLASS) MOHS, 4.1.9 Support an uninterrupted supply of quality laboratory reagents and supplies. MOHS, 4.1.13 Conduct molecular characterization of any resistance determinants from Multi-drug resistance (MDR) organisms MOHS 4.1.14 Establish Repository of MDR isolates MOHS 4.2 Strengthen laboratory and diagnostic capacity to monitor AMR and antimicrobial residue at national and regional level in the animal health and agricultural sector 4.2.1 Assess existing capacities for monitoring AMR and detecting antimicrobial residues; MAFFS 4.2.2 Establish laboratory capacity for screening of antibiotic residues in food products locally produced or imported and AMR in pathogens isolated from food products. 4.2.3 Establish AMR laboratory capacity to conduct antibiotic surveillance in pathogens isolated from food-producing animals MAFFS 32 4.2.4 Strengthen national laboratory capacity to monitor AMR and detect antimicrobial residues in food products and the environment; MAFFS 4.2.5 Training of lab personnel to make analyses – microbiological and physiochemical testing of animals and animal products; MAFFS 4.2.6 Field testing of antibiotics for active ingredients. MAFFS 4.3 Strengthen laboratory capacity to monitor AMR at national and regional level in the environment sector. 4.3.1 Develop a laboratory capacity to analyzed water and Soil samples for possible AM residue EPA 4.3.2 Capacity building via training of EPA-SL to analyze potential AM contaminated samples. EPA 4.3.3 Conduct an inventory aimed at identifying AMR contaminated site in country. EPA 4.4 Develop a Geographic Information System (GIS) Map indicating contaminated and sampling sites in Sierra Leone. 4.4.1 Establish a monitoring and surveillance plan EPA 4.4.2 Establish an electronic database to assess trend. EPA Objective 5: Set-up a national antimicrobial resistance surveillance system Surveillance 33 Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 5.1 Establish an integrated AMR surveillance system 5.1.1 Establish coordinating centre for AMR to systematically collect, analyse and report antimicrobial use and resistance MOHS, MAFFS, EPA 5.1.2 Develop an AMR one health surveillance plan through the establishment a surveillance technical group with an endorsed TOR to develop the One Health surveillance system to include routine, sentinel and surveys MOHS, MAFFS, EPA 5.1.3Develop forms, tracking software and reports on the use of antibiotics and drug resistance. MOHS, MAFFS, EPA 5.1.4 Organize regular review meetings among relevant groups of stakeholders to review data on both antimicrobial use and resistance, and take practical steps to translate those data into actions, such as informing new or revision of policies and practice guidelines. MOHS, MAFFS, EPA 5.1.5 Establish a mandatory requirement for submission of all AMR data including i.e. from vertical programmes, animal health and food safety in the public, NGO, and private sectors MOHS, MAFFS, EPA 5.2 Establish antimicrobial use surveillance in animal health and agriculture sectors 5.2.1 Develop plans to monitor antimicrobial use in animals and crop production. MOHS, MAFFS, EPA 5.2.2 Conduct antimicrobial use surveys/studies at national, district and community level, and also in veterinary and agricultural settings. MOHS, MAFFS, EPA 5.2.3 Strengthen mechanisms to check for levels of antimicrobial agents in imported as well as locally produced animal and plant food products, and also levels of antimicrobial discharge in the environment such as waterways. MOHS, MAFFS, EPA 34 5.2.4 Establish systems to collect data on national level sales or consumption of antibiotics, prescribing practices and appropriate antibiotic use at selected health care settings, MOHS, MAFFS, EPA 5.3 Establish AMR surveillance in environmental sector 5.3.1 Identify and implement ‘clean up’ of AMR Contaminated sites. MOHS, MAFFS, EPA 5.3.2 Incorporate the concept of AMR into the waste managment policies of companies and Industries. MOHS, MAFFS, EPA 5.3.3 Strengthen mechanisms to check for levels of antimicrobial discharge in the environment such as waterways MOHS, MAFFS, EPA 5.3.4 Incorporate AMR Concept into the Terms and Conditions of EIA Licenced Holders. MOHS, MAFFS, EPA 5.3.5 Develop and popularise guidelines on the safe disposal of AMR product at industries and health Facilities. MOHS, MAFFS, EPA 5.4 Improve information dissemination for antimicrobial surveillance and antimicrobial use 5.4.1 Disseminate monthly AMR reports to the antimicrobial stewardship committee in healthcare facilities MOHS, MAFFS, EPA 5.4.2 Disseminate quarterly AMR reports among facility health providers and DHMTs to increase awareness of AMR profiles among circulating pathogens MOHS, MAFFS, EPA 5.4.3 Provide annual AMR surveillance reports to committees responsible for revising standard treatment guidelines, Clinical Practice Guidelines (CPGs), Essential Medicines List (EML), and Infection Prevention and Control (IPC) guidelines. MOHS, MAFFS, EPA 35 GLOBAL STRATEGIC OBJECTIVE 4: REDUCE THE INCIDENCE OF INFECTION THROUGH EFFECTIVE SANITATION, HYGIENE AND INFECTION PREVENTION MEASURES Objective 6: Identify operational research priorities for responsible use of antimicrobial agents and better practice in infection prevention in human and animal health Research and development Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 6.1 Develop a national research agenda on AMR 6.1.1 Engage relevant experts to identify current gaps in knowledge and potential research topics. MOHS, MAFFS, EPA 6.1.2 Develop research guidelines on AMR MOHS, MAFFS, EPA 6.1.3 Undertake research on AMR MOHS, MAFFS, EPA 6.2 Establish a system for sharing data on AMR research 6.2.1 Organize multisector national AMR scientific symposiums MOHS, MAFFS, EPA 6.2.2 Establish a national AMR data repository MOHS, MAFFS, EPA Objective 7: Strengthen the national infection prevention and control programme for human health Infection prevention and control in health care Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 7.1 improve sensitization and monitoring of IPC practices 7.1.1 Carry out awareness meetings on hand hygiene and prevention of healthcare-associated infections at training institutions, health facilities, and veterinary services MOHS, MAFFS, EPA 36 7.1.2 Conduct Hand hygiene audits MOHS, MAFFS, EPA 7.1.3 Strengthen IPC measures in human health facilities, including long-term care and congregate settings MOHS, MAFFS, EPA 7.1.4 Upgrade training curriculum for IPC training to include AMR MOHS, MAFFS, EPA 7.1.5 Education and training of healthcare workers on AMR MOHS, MAFFS, EPA 7.1.6 Establish HAI surveillance programmes MOHS, MAFFS, EPA 7.1.7 Conduct supervision of IPC implementation MOHS, MAFFS, EPA 7.1.8 Monitor implementation of IPC quarterly with timely feedback. MOHS, MAFFS, EPA Objective 8: Introduce infection prevention and control programmes in veterinary settings and animal husbandry. Infection prevention in animal health, veterinary and agriculture Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 8.1 Include hygiene and infection prevention and control as core (mandatory) content in training and education of veterinary professionals. 8.1.1 Include hygiene and infection prevention and control in undergraduate curricula for animal health professionals. MOHS, MAFFS, EPA 8.2 Implement IPC programmes across the agricultural and 8.2.1 Establish IPC programmes in animal health, agriculture and fisheries, including health MOHS, MAFFS, EPA 37 fisheries sectors inspections of abattoirs, farms and communities, and monitor and improve adherence to national/facility IPC policies and standards Objective 9: Limit the development and spread of AMR in the community by infection prevention and control measures Hygiene, sanitation and infection prevention in the Community Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 9.1 Promote personal hygiene by social mobilization and behavioural change activities. 9.1.1 Estimate knowledge of personal hygiene in different social groups as a basis for the social mobilization campaigns. MOHS, MAFFS, EPA 9.1.2 Promote hygiene, sanitation and other behaviours that contribute to infection prevention in the community MOHS, MAFFS, EPA 9.2 Encourage continued increases in vaccination rates at veterinary and human health facilities to prevent infection 9.2.1 Promote vaccination amongst veterinary, human health workers and the general public. MOHS, MAFFS, MCPLE Objective 10: Strengthen health care waste management at all levels Waste management Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 10.1 Reduce environmental contamination with resistant pathogens and antimicrobial residues 10.1.1 Develop systems for safe collection, transport and disposal of waste from human health, animal and agricultural facilities through the establishment an effective waste management system, specifically addressing water sewage and landfills (solid waste) involving agricultural and MOHS, MAFFS, EPA 38 medical waste 10.1.2: Establish national and subnational monitoring system for waste management MOHS, MAFFS, EPA GLOBAL STRATEGIC OBJECTIVE 5: OPTIMIZE THE USE OF ANTIMICROBIAL AGENTS IN HUMAN, ANIMAL AND PLANT HEALTH Objective 11: Ensure uninterrupted access to high-quality antimicrobial medicines Regulated access to high quality microbials Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 11.1 Improve access, strengthen regulation and supply chain management for antimicrobial agents. 11.1.1 Establish or strengthen the quality management system for the supply of medicines, covering storage, transport, distribution and inventory management MOHS, MAFFS, EPA 11.1.2 Strengthen national mechanisms for registration of antimicrobial medicines through the Pharmacy Board of Sierra Leone(PBSL) MOHS, MAFFS, EPA 11.1.3 Conduct monitoring and post marketing surveillance of antimicrobials circulating in the market (public and private sectors) MOHS, MAFFS, EPA 11.1.4 Build capacity for effective and enforceable regulation of antimicrobial management, including quality assurance of all imported products including antimicrobials, reagents and pesticides and standardization of diagnostic equipment MOHS, MAFFS, EPA 11.1.5 Review and enforce use of a national and MOHS, MAFFS, EPA 39 institutional essential medicine list guided by the WHO model list of essential medicines and national AMR data 11.1.6 Develop clinical practice guidelines such a national formulary, standard treatment guidelines with participation of relevant stakeholders MOHS, MAFFS, EPA 11.1.7 Provide appropriate training for personnel engaged in supply chain management and medicines regulation MOHS, MAFFS, EPA 11.1.8 Conduct audit inspections of pharmaceutical importers to check on the quantities of antimicrobial agents (for human use) imported and distributed as well as the quantity remaining (if any) MOHS, MAFFS, EPA 11.1.9 Conduct follow - up audit inspections of medical prescriptions, prescription registers of community retail pharmacy outlets and government dispensaries to check whether antimicrobial agents were dispensed on prescription or not. MOHS, MAFFS, EPA 11.1.10 Development of antimicrobial prescription and utilization registers for deployment at Pharmacies and Drugstores MOHS, MAFFS, EPA 11.1.11 Equip the national quality control laboratory to perform quality assays and strengthen the national pharmacovigilance reporting systems MOHS, MAFFS, EPA 40 11.1.12. Develop guidelines related to the prescription, sales, dispensation, and administration of antimicrobials. MOHS, MAFFS, EPA . Objective 12: Improve and measure appropriate use of antimicrobial agents in health care Antimicrobial stewardship (AMS) Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 12.1 Create formal AMS programmes in health care facilities 12.1.1 Develop policy and regulations for AMS MOHS, MAFFS, EPA 12.1.2 Establish AMS committees in health facilities MOHS, MAFFS, EPA 12.1.3 Develop a list of critical important antibiotics to human health whose access should be controlled (e.g. Fluoroquinolones, third and fourth generation cephalosporins, carbapenems, amikacin, vancomycin). MOHS, MAFFS, EPA 12.1.4 Develop and implement national and facility-level antimicrobial stewardship programs, including medicine use reviews/evaluations, and implementation and monitoring of the use of STGs in both human and veterinary settings. MOHS, MAFFS, EPA 12.1.5 Promote and monitor the use of evidence based rapid diagnostic tests to facilitate diagnosis and optimal antimicrobial treatment MOHS, MAFFS, EPA 12.1.6 Establish or strengthen capacity of existing drug and therapeutics committees (DTCs) in carrying out antimicrobial stewardship MOHS, MAFFS, EPA 41 containment activities 12.1.7 Establish drug information centres (DICs) to provide information on antibiotic use and resistant MOHS, MAFFS, EPA Objective 13: Ensure prudent use of antimicrobial agents in terrestrial and aquatic animals and agriculture Antimicrobial use in animal health and agriculture Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 13.1 Establish national policies on use of antimicrobial agents in animals, agriculture and fisheries. 13.1.1 Develop guidelines for the use of antimicrobials in food-producing animals based on the WHO list of Critically Important Antimicrobials(CIA) MOHS, MAFFS, EPA 13.1.2 Establish a strong regulatory framework for authorization and control of the quality of veterinary medicines. MOHS, MAFFS, EPA 13.1.3 Establish regulation for the restriction of non-therapeutic use of antimicrobials (e.g. growth promoters) in food-producing animals and use of critically important antimicrobials for human medicine in food- producing animals. MOHS, MAFFS, EPA 13.1.4 Develop/review National Medicines, pesticides and national livestock Policy to address AMR MOHS, MAFFS, EPA GLOBAL STRATEGIC OBJECTIVE 6: DEVELOP THE ECONOMIC CASE FOR SUSTAINABLE INVESTMENT AND ACTIONS TO COMBAT AMR Objective 14: Prepare the economic case for sustainable investment and actions to fight AMR. 42 Sustainability of antimicrobial resistance interventions Strategic interventions Activities Responsible institution/agency Yr 1 Yr2 Yr3 Yr4 Yr5 14.1. Prepare a plan to secure and use financing for implementation of the AMR strategic plan 14.1.1 Assess investment requirements for implementation of the strategic plan. MOHS, MAFFS, EPA 14.2 Strengthen partnership and governance to support and enhance AMR containment efforts 14.2.1 Build and expand local, national, regional and international partnerships and coalitions in support of AMR containment, including public private partnerships MOHS, MAFFS, EPA 14.2.2 Strengthen AMR containment-related governance through a national multi-sectoral and multi-disciplinary coordinating team, and focal points at different levels with clearly defined terms of reference, mandates and accountability MOHS, MAFFS, EPA 14.3 Strengthen advocacy for funding and support for AMR containment 14.3.1 Advocate for budgetary funding for AMR containment efforts from government, donors, and the private sector MOHS, MAFFS, EPA 14.3.2 Include relevant AMR related activities into MoHS annual operational plan and MoHS strategy MOHS, MoFED 14.3.3 Include relevant AMR related activities into MAFFS annual operational plan and MAFFS strategy MAFFS, MoFED 14.3.4 Include relevant AMR related activities into EPA annual operational plan and EPA strategy EPA, MoFED 14.4 Coordinate national 14.4.1 Conduct research and promote information MOHS, MAFFS, EPA 43 research efforts and information sharing sharing with regard to various aspects of AMR containment including understanding and awareness of AMR, surveillance of antimicrobial use and resistance, infection prevention/control, optimized use of antimicrobials, and development and diffusion of new antimicrobials, vaccines, diagnostics, and novel delivery methods 14.4.2 Develop AMR research Agenda for human, animal and environmental health MOHS, MAFFS, EPA 14.4.3 Provide incentive and research funding for researches on AMR MOHS, MAFFS, EPA 44 5. MONITORING AND EVALUATION PLAN Monitoring and Evaluation (M and E) of the strategic plan using process and outcome indicators is critical to ascertaining objectively the effects of the interventions to combat AMR. Each activity bears a monitoring indicator to be measured in the process of its implementation. Individual Ministries/ institutions/bodies will have the responsibility for keeping tract on the relevant strategic plan activities and feeding information, findings and recommendations into the overall M and E process. A mid-term review will be done after two years to monitor the implementation of the strategic plan. End of year one review will be done in 2019 and end of term evaluation will be conducted in 2022. Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline 1.1.1 Define membership to be representative of all stakeholders and appoint persons into the NMCG Membership of NMCG defined Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 1.1.2 Develop and approve TOR of NMCG TOR developed and published Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 1.2.2 Designate national focal persons for AMR in the health, animal and environmental sectors National focal persons designated Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report Available but not formalised 1.1.3 Establish a secretariat for the NMCG Secretariat for NMCG established Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 1.1.4 Organise quarterly meetings to review Minutes of 4 times/year Key informants at AMR surveillance None 45 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline progress towards implementation of NAP AMR meetings MOHS, MAFFS and EPA programme implementation report available 1.2.1 Expand terms of reference (TOR) of National one health committee to include AMR Expanded TOR Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 1.3.1 Develop a roadmap for the implementation of the AMR strategic plan Roadmap Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 1.3.2 Cost the AMR strategic plan Costed AMR plan Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 2.1.1. Estimate awareness and knowledge through knowledge, attitude, practice and behavioural studies in the general populace and professional groups- health, veterinary, farmers and food processing sector, pharmaceuticals Report, Publication Once Report Survey None available 2.1.2 Develop and disseminate national communication strategy for AMR Strategy developed Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None available 2.2.1 Carry out advocacy and sensitization meetings for parliamentarians, local government, chiefdom chiefs, at national, district and chiefdom levels Minutes of meetings Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 46 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline 2.2.2 Develop and disseminate communication messages in the print and broadcast media and IEC materials (including billboards, posters, radio spots)to guide health workers, pharmacists, communities on prevention of drug resistance Communication messages and materials developed and disseminated Once every year Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 2.2.3 Engage non-governmental organizations, Civil Society Organizations and the media to deliver messages on AMR Meetings held with key stakeholders and messages published (audio, video, print, flyers etc) Once every year Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 2.2.4 Commemorate Antibiotic awareness week Improved awareness among key stakeholders Once every year Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 3.1.1. Develop modules on AMR and related topics in primary, secondary and tertiary education curricula Modules developed Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 3.2.1 Engage professional registration boards for inclusion of AMR CPE as pre requisite for licence renewal Policy, guideline Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 47 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline 3.2.2 Conduct Annual scientific symposium on AMR for human, animal and veterinary professionals Report Once every year Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 3.3.1 Engage stakeholder in the educational sector in a consultative meeting to develop curriculum for AMR Curriculum Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 3.3.2 Train Professional, through short courses, in-service and pre-service programmes in the human health, veterinary, food production and agriculture sectors on AMR Report Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 3.4.1. Review and include AMR and related topics in secondary and tertiary education curricula Review curricula Once Key informants at MOHS, MAFFS and EPA AMR surveillance programme implementation report None 4.1.1 Designate a national laboratory for AMR surveillance with clearly articulated TOR Laboratory and TOR Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.2 Appoint a focal person for AMR surveillance in the national AMR laboratory with defined roles and responsibilities Focal person Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.3 Standardize SOPs for laboratory testing for AMR SOPs Once Key informants at MOHS, MAFFS AMR surveillance programme None 48 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline implementation report 4.1.4. Conduct capacity building for laboratory staff on AMR Report Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.5 Identify, designate and support regional laboratories for AMR sentinel surveillance Lab capacitate for surveillance Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.6 Standardize AMR reporting system across laboratories Instructions, SOP and forms Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.7 Enrol national and regional laboratories in external quality assurance schemes, monitor and evaluate their performance, and implement corrective actions. Improved microbiology diagnostics including AST Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.8 Enrol national and regional laboratories in GLASS Improved testing proficiency Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 4.1.8 Support an uninterrupted supply Improved supply chain for lab Once Key informants at, MAFFS, MOHS, EPA AMR surveillance programme implementation None 49 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline of quality laboratory reagents and supplies. consumables report 4.2.1 Establish AMR laboratory capacity to conduct antibiotic surveillance in pathogens isolated from food-producing animals Routine AMR surveillance Once Key informants at MAFFS AMR surveillance programme implementation report None 4.2.2 Establish laboratory capacity for screening of antibiotic residues in food products locally produced or imported and AMR in pathogens isolated from food products. Routine screening of antibiotics in food products Once Key informants at, MAFFS AMR surveillance programme implementation report None 5.1.1 Establish coordinating centre for AMR to systematically collect, analyse and report antimicrobial use and resistance AMR centre for data management created Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 5.1.2 Develop an AMR one health surveillance plan through the establishment a surveillance technical group with an endorsed TOR to develop the One Health surveillance system to include routine, sentinel and surveys TOR, One health plan developed Once Key informants at MOHS, MAFFS , EPA AMR surveillance programme implementation report None 50 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline 5.1.3Develop forms, tracking software and reports on the use of antibiotics and drug resistance Forms, software and report Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 5.1.4 Organize regular review meetings among relevant groups of stakeholders to review data on both antimicrobial use and resistance, and take practical steps to translate those data into actions, such as informing new or revision of policies and practice guidelines Minutes Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 5.1.5 Establish a mandatory requirement for submission of all AMR data including i.e. from vertical programmes, animal health and food safety in the public, NGO, and private sectors Policy and guideline Once Key informants at MOHS, MAFFS AMR surveillance programme implementation report None 5.2.1 Develop plans to monitor antimicrobial use in animals and crop production Monitoring plan Once Key informants at MAFFS AMR surveillance programme implementation report None 5.2.2 Conduct antimicrobial use surveys/studies at national, district and community level, and also in veterinary and Report Once Key informants at MAFFS , Report Survey None 51 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline agricultural settings 5.2.3 Strengthen mechanisms to check for levels of antimicrobial agents in imported as well as locally produced animal and plant food products, and also levels of antimicrobial discharge in the environment such as waterways. Routine monitoring of antimicrobials in food products Once Key informants at MOHS, MAFFS, EPA Key informant interview None 5.2.4 Establish systems to collect data on national level sales or consumption of antibiotics, prescribing practices and appropriate antibiotic use at selected health care settings, Report Once Key informants at MOHS, Key informant interview None 5.3.1 Identify and implement clean-up of AMR Contaminated sites Report Once Key informants at EPA Key informant interview None 5.3.2 Incorporate the concept of AMR into the waste managment policies of companies and Industries Policy Once Key informants at EPA Key informant interview None 5.3.3 Strengthen mechanisms to check for levels of antimicrobial discharge in the environment such as waterways Routine monitoring of Once Key informants EP A Key informant interview None 52 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline antimicrobial discharge 5.3.4 Incorporate AMR Concept into the Terms and Conditions of EIA Licenced Holders. Terms and conditions Once Key informants at EPA Key informant interview None 5.3.5 Develop and popularise guidelines on the safe disposal of AMR product at industries and Health Facilities Guidelines Once Key informants at MOHS, MAFFS, EPA Key informant interview None 5.4.1 Disseminate monthly AMR reports to the antimicrobial stewardship committee in healthcare facilities Report Once Key informants at MOHS, Key informant interview None 5.4.2 Disseminate quarterly AMR reports among facility health providers and DHMTs to increase awareness of AMR profiles among circulating pathogens Report Once Key informants at MOHS Key informant interview None 5.4.3 Provide annual AMR surveillance reports to committees responsible for revising standard treatment guidelines, Clinical Practice Guidelines (CPGs), Essential Medicines List (EML), and Infection Annual report Once Key informants at MOHS Key informant interview None 53 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline Prevention and Control (IPC) guidelines. 6.1.1 Engage relevant experts to identify current gaps in knowledge and potential research topics. Gap identify Once Key informants at MOHS, MAFFS, EPA Key informant interview None 6.1.2 Develop research guidelines on AMR Guidelines Once Key informants at MOHS, MAFFS, EPA Key informant interview None 6.1.3 Undertake research on AMR Report, publication Once Key informants at MOHS, MAFFS, EPA Key informant interview None 6.2.1 Organize multisector national AMR scientific symposiums Report Once/year Key informants at MOHS, MAFFS, EPA Key informant interview None 6.2.2 Establish a national AMR data repository Repository None Key informants at MOHS, MAFFS, EPA Key informant interview None 7.1.1 Carry out awareness meetings on hand hygiene and prevention of healthcare associated infections at training institutions, health facilities, and veterinary services Report Annually Key informants at MOHS, MAFFS, EPA Key informant interview Available 7.1.2 Conduct Hand hygiene audits Improved IPC Annually Key informants at Key informant Available 54 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline measures MOHS, MAFFS, EPA interview 7.1.3 Strengthen IPC measures in human health facilities, including long-term care and congregate settings Improved IPC measures Annually Key informants at MOHS, MAFFS, EPA Key informant interview Available 7.1.4 Upgrade training curriculum for IPC training to include AMR Curriculum Once Key informants at MOHS, MAFFS, EPA Key informant interview Available 7.1.5 Education and training of healthcare workers on AMR Report Annually Key informants at MOHS, MAFFS, EPA Key informant interview Available 7.1.6 Establish HAI surveillance programmes Routine monitoring in place Once Key informants at MOHS, MAFFS, EPA Key informant interview Available 7.1.7 Conduct supervision of IPC implementation Report Annually Key informants at MOHS, MAFFS, EPA Key informant interview Available 7.1.8 Monitor implementation of IPC quarterly with timely feedback. Report Quarterly Key informants at MOHS, MAFFS, Key informant interview Available 55 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline EPA 8.1.1 Include hygiene and infection prevention and control in undergraduate curricula for animal health professionals. Curricula Once Key informants at MOHS, MAFFS, EPA Key informant interview None 8.2.1 Establish IPC programmes in animal health, agriculture and fisheries, including health inspections of abattoirs, farms and communities, and monitor and improve adherence to national/facility IPC policies and standards Routine monitoring improved Annually Key informants at MOHS, MAFFS, EPA Key informant interview None 9.1.1 Estimate knowledge of personal hygiene in different social groups as a basis for the social mobilization campaigns. Report, publication Once Key informants at MOHS, MAFFS, EPA Key informant interview None 9.1.2 Promote hygiene, sanitation and other behaviours that contribute to infection prevention in the community Improved behaviour Annually Key informants at MOHS, MAFFS, EPA Key informant interview None 9.2.1 Promote vaccination amongst veterinary, human health workers and the general public. Improved vaccination Annually Key informants at MOHS, MAFFS, EPA Key informant interview None 10.1.1 Develop systems for safe collection, transport and disposal of waste from human health, animal and agricultural facilities Effective waste management system Annually Key informants at MOHS, MAFFS, Key informant interview None 56 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline through the establishment an effective waste management system, specifically addressing water sewage and landfills (solid waste) involving agricultural and medical waste established EPA 10.1.2: Establish national and subnational monitoring system for waste management Monitoring system established Annually Key informants at MOHS, MAFFS, EPA Key informant interview None 11.1.1 Establish or strengthen the quality management system for the supply of medicines, covering storage, transport, distribution and inventory management Quality management system improved Annually Key informants at MOHS, Key informant interview None 11.1.2 Strengthen national mechanisms for registration of antimicrobial medicines through the Pharmacy Board of Sierra Leone(PBSL) Mechanism improved Annually Key informants at MOHS PBSL Key informant interview Available 11.1.3 Strengthen the monitoring and post marketing surveillance of antimicrobials circulating in the market (public and private sectors) Report Annually Key informants at MOHS PBSL Key informant interview Available 57 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline 11.1.4 Strengthen and build capacity for effective and enforceable regulation of antimicrobial management, including quality assurance of all imported products including antimicrobials, reagents and pesticides and standardization of diagnostic equipment Quality assurance of antimicrobials improved Annually Key informants at MOHS PBSL Key informant interview Available 11.1.5 Review and enforce use of a national and institutional essential medicine list guided by the WHO model list of essential medicines and national AMR data Updated EML Every 3 years Key informants at MOHS DDMS Key informant interview Available 11.1.6 Develop clinical practice guidelines such a national formulary, standard treatment guidelines with participation of relevant stakeholders Clinical practice guidelines developed Once Key informants at MOHS Key informant interview Available 11.1.7 Provide appropriate training for personnel engaged in supply chain management and medicines regulation Instruction materials, training manuals, Attendance sheets, certificates Annually Key informants at MOHS Key informant interview Available 11.1.8 Conduct audit inspections of pharmaceutical importers to check on the quantities of antimicrobial agents (for human use) imported and distributed as well as the Report Annually Key informants at MOHS Key informant interview Available 58 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline quantity remaining (if any) 11.1.9 Conduct follow - up audit inspections of medical prescriptions, prescription registers of community retail pharmacy outlets and government dispensaries to check whether antimicrobial agents were dispensed on prescription or not. Report Annually Key informants at MOHS Key informant interview Available 11.1.10 Development of antimicrobial prescription and utilization registers for deployment at Pharmacies and Drugstores Registers Annually Key informants at MOHS Key informant interview None 11.1.11 Equip the national quality control laboratory to perform quality assays and strengthen the national pharmacovigilance reporting systems PV and NPQC lab equipped Annually Key informants at MOHS Key informant interview None 11.1.12. Develop guidelines related to the prescription, sales, dispensation, and administration of antimicrobials. Guidelines Once Key informants at MOHS Key informant interview None 12.1.1 Develop policy and regulations for AMS Policy, regulation Once Key informants at MOHS Key informant interview None 12.1.2 Establish AMS committees in health facilities Nomination letters, TOR and minutes Once Key informants at MOHS Key informant interview None 12.1.3 Develop a list of critical antibiotics to human health whose access should be controlled (e.g. Fluoroquinolones, third and List of CIA Once Key informants at MOHS Key informant interview None 59 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline fourth generation cephalosporins, carbapenems, amikacin, vancomycin). 12.1.4 Develop and implement national and facility-level antimicrobial stewardship programs, including medicine use reviews/evaluations, and implementation and monitoring of the use of STGs in both human and veterinary settings. Reports Annually Key informants at MOHS Key informant interview None 12.1.5 Promote and monitor the use of evidence-based rapid diagnostic tests to facilitate diagnosis and optimal antimicrobial treatment Report Annually Key informants at MOHS Key informant interview None 12.1.6 Establish or strengthen capacity of existing drug and therapeutics committees (DTCs) in carrying out antimicrobial stewardship containment activities Nomination letters of members, TOR and minutes Once Key informants at MOHS Key informant interview None 12.1.7 Establish drug information centres (DICs) to provide information on antibiotic use and resistant TOR Once Key informants at MOHS Key informant interview None 13.1.1 Develop guidelines for the use of antimicrobials in food-producing animals based on the WHO list of Critically Important Antimicrobials(CIA) Guideline Once Key informants at MAFFS Key informant interview None 13.1.2 Establish/strengthen strong regulatory framework for authorization and Framework strengthen Once Key informants at MAFFS Key informant interview None 60 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline control of the quality of veterinary medicines. 13.1.3 Establish regulation for the restriction of non-therapeutic use of antimicrobials (e.g. growth promoters) in food-producing animals and use of critically important antimicrobials for human medicine in food producing animals. Policy, regulation Once Key informants at MAFFS Key informant interview None 13.1.4 Develop/review National Medicines, pesticides and national livestock Policy to address AMR Policy Once Key informants at MAFFS, MOHS, EPA Key informant interview None 14.1.1 Assess investment requirements for implementation of the strategic plan. Report Once Key informants at MAFFS, MOHS, EPA Key informant interview, Investment need assessment report None 14.2.1 Build and expand local, national, regional and international partnerships and coalitions in support of AMR containment, including public-private partnerships Partnerships established, MOU Once Key informants at MAFFS, MOHS, EPA Key informant interview None 14.2.2 Strengthen AMR containment-related governance through a national multi sectoral and multi-disciplinary coordinating team, and focal points at different levels with clearly defined terms of reference, mandates and accountability TOR, nomination letters Once Key informants at MAFFS, MOHS, EPA Key informant interview None 61 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline 14.3.1 Advocate for budgetary funding for AMR containment efforts from government, donors, and the private sector AMR activities are budgeted for in the government and donnors annual operational plan Annually Key informants at MAFFS, MOHS, EPA Key informant interview None 14.3.2 Include relevant AMR related activities into MoHS annual operational plan and MoHS strategy AMR activities are budgeted for in the MOHS annual operational plan Annually Key informants at MOHS Key informant interview 14.3.3 Include relevant AMR related activities into MAFFS annual operational plan and MAFFS strategy AMR activities are budgeted for in the MAFFS annual operational plan Annually Key informants at MAFFS Key informant interview 14.3.4 Include relevant AMR related activities into EPA annual operational plan and EPA strategy AMR activities are budgeted for in the EPA annual operational plan Annually Key informants at EPA Key informant interview 14.4.1 Conduct research and promote information sharing with regard to various aspects of AMR containment including understanding and awareness of AMR, surveillance of antimicrobial use and resistance, infection prevention/control, optimized use of antimicrobials, and development and diffusion of new antimicrobials, vaccines, diagnostics, and Report, publication Once Key informants at MAFFS, MOHS, EPA Key informant interview None 62 Planning element linked to strategic plan Indicator Frequency of data collection Data source Method Baseline novel delivery methods. 14.4.2 Develop AMR research Agenda for human, animal and environmental health. List of research priority areas Once Key informants at MAFFS, MOHS, EPA Key informant interview None 14.4.3 Provide incentive and research funding for researches on AMR. Increase number of projects Once Key informants at MAFFS, MOHS, EPA Key informant interview None 63 6. REFERENCES 1. WHO. (2014). Antimicrobial Resistance Global Report on Surveillance. 2. WHO. (2015). Global Action Plan for Antimicrobial Resistance (GAP-AMR). 3. WHO. (May 2015). WHA decision point: WHA A/68/20, A68/VR/9. 4. Joint External Evaluation report 2016