National Action Plan (NAP) on Antimicrobial Resistance 2025-2029

2.1 — Summary (ISK) 52

2.1 Summary (ISK) 52 2. Limit the spread of antibiotic resistance through

2.2 — Cost estimates of individual actions (ISK) 53

2.2 Cost estimates of individual actions (ISK) 53 information dissemination, education, and prevention 17

2.3 — Cost estimates of stakeholders (ISK) 59

2.3 Cost estimates of stakeholders (ISK) 59 3. Improve knowledge of antibiotic resistance through monitoring and scientific research 19 Tables 4. Contain the spread of antibiotic resistance through Table 1. Proportion of selected antibiotic resistant intervention measures 21 bacteria (%) in humans in 2022 and goals for 2029 28 5. Increase participation in international cooperation Table 2. Antibiotic use in humans (DID) in 2022 and goals for 2029 29 on actions against antibiotic resistance 22 Table 3. Proportion of humans fully vaccinated (%) 6. Ensure coordination and management of actions in 2022 and goals for 2029 29 against antibiotic resistance in Iceland for the future 23 Table 4. Proportion of selected antibiotic resistant Cost Estimates of Activities 24 bacteria (%) in animals and food in 2022 and goals for 2029 30 Responsible Stakeholders for Activities 25 Table 5. Antibiotic use in animals (mg/PCU*) Prioritisation of Activities 26 in 2022 and goals for 2029 30 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 5 Summary Antibiotic resistance is one of the greatest health threats facing the world today, and the threat is increasing each year. Although antibiotic resistance is not as significant a problem in Iceland as it is in many other countries, antibiotic-resistant bacteria respect no borders, and the problem has in- creased here as elsewhere in recent years. It is foreseeable that increased antibiotic resistance will cause difficulties in treating various diseases and infections, increase mortality rates, and raise healthcare costs. International organizations have recently highlighted this danger and urged nations worldwide to join forces to prevent the spread of antibiotic-resis- tant bacteria before it is too late. Each nation is encouraged to develop action plans and set goals and benchmarks. Since the causes of antibiotic resistance are diverse and interconnected, a One Health approach is en- couraged, meaning that actions need to target humans, animals, food, and the environment. The Icelandic government's action plan against antibiotic resistance spans a five-year period, from 2025 to 2029. It includes six actions encompassing 24 goals and 75 activities that need to be implemented. The activities are prioritised, and the cost of their implementation is assessed. July 2024 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 6 The six actions upon which the action plan is based are: 1 Promote targeted and prudent use of antibiotics in humans and animals. 2 Limit the spread of antibiotic resistance through information dissemination, education, and prevention. 3 Improve knowledge of antibiotic resistance through surveillance and scientific research. 4 Limit the spread of antibiotic resistance through interventions. 5 Increase participation in international cooperation on actions against antibiotic resistance. 6 Ensure coordination and management of actions against antibiotic resistance in the future to come. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 7 Work is already ongoing in various activities specified in the plan. The total basic cost of all activities over the five-year period of the plan is estimated to be about 500 million ISK at current prices. To implement all activities within the plan's period, an additional estimated 1.2 billion ISK will be needed. The aim is to implement as many of the plan's activities as possible within the specified time frame and to ensure funding. Additionally, their costs will be reassessed at least annually during the plan's period by a special working group appointed by the Minister of Health. Only through targeted and extensive actions, along with follow-up, will it be possible to limit the spread of antibiotic resistant bacteria. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 8 Abbreviations and Definitions AMEG Classification Antimicrobial advise ad hoc Expert Group. EC European Commission. Classification by the European Medicines Agency of antibiotics based on potential public ECDC European Centre for Disease health consequences of increased resistance Prevention and Control. when these drugs are used in animals and the need for these drugs in veterinary medicine. EFSA European Food Safety Authority. AMR Antimicrobial resistance. EMA European Medicines Agency. ATC Anatomical Therapeutic Chemical. EL The Directorate of Health in Iceland. Classification of drugs by organ systems. ESBL Extended-spectrum beta-lactamases. AWaRe Classification WHO classification according to the prioritisa- WHO tion of antibiotics ("Access, Watch, Reserve"). EU European Union. BÍ The Farmers' Association of Iceland. FRN Ministry of Social Affairs and Labour. COVID-19 Coronavirus disease 2019. FAO Food and Agriculture Organization of the United Nations. DID Defined daily dosage/1000/day. Standardised daily doses per 1,000 inhabitants per day. GDP Gross Domestic Product. DÍ The Icelandic Veterinary Association. H. influenzae Haemophilus influenzae. E. coli Escherichia coli. HA University of Akureyri. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 9 Heilsuvera An official website on various common PCU Population Correction Unit. Estimated weight and individual health information. of livestock in the country each year. HH Primary Health Care of the Capital Area. SAF Association of Travel Service. HRN Ministry of Health. SAk Akureyri Hospital. HVIN Ministry of Higher Education, SFV Association of Welfare Service Companies. Science and Innovation. SVEID Department of Bacteriology and Virology ISK Icelandic krona. at Landspítali. Keldur Institute for Experimental Pathology, SVL Chief Epidemiologist. University of Iceland. Sýklalyfjaávísun Prescription of antibiotics and medical LSH Landspítali, the National University orders for outpatients and inpatients Hospital of Iceland. at hospitals or nursing homes. MAR Ministry of Food, Agriculture and Fisheries. UN United Nations. MAST Icelandic Food and Veterinary Authority. URN Ministry of the Environment, Energy and Climate. MATÍS Company specialising in food research and biotechnology. UST Environment Agency of Iceland. MRN Ministry of Education and Children. WGS Whole genome sequencing. OECD Organisation for Economic Cooperation WHO World Health Organization. and Development. WOAH World Organisation for Animal Health (former OIE). One Health Approach integrating human, animal, food and environmental health. ÞÍH Development Centre of the Icelandic Primary Health Care. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 10 Introduction The discovery of antibiotics almost a century ago proved to be one of the With the increasing resistance to antibiotics, the treatment of patients most remarkable discoveries in the history of medicine. The advent of anti- with the aforementioned diseases will be significantly limited, and the biotics brought about radical changes in the treatment of severe bacterial cost of their treatment will rise due to the increased number of hospitalisa- infections in both humans and animals, and it is safe to say that they have tions required and longer hospital stays. Food security will also decrease as prevented millions of deaths and severe consequences of infections. Addi- antibiotic resistance affects animal health and consequently food production3. tionally, antibiotics enable patients with serious diseases, such as cancer and various autoimmune diseases, to receive immunosuppressive treat- The growing spread of antibiotic resistance thus not only causes increasing ment, which increases the likelihood of infections. difficulties in treating infected individuals but also poses a serious threat to humans and animals and will result in significant financial expenditures 4. Antibiotic resistance refers to the ability of pathogens to thrive and multiply A recent article in The Lancet 5 estimated that nearly 5 million people died in the presence of antibiotics that would typically kill or inhibit their growth. due to infections caused by antibiotic resistant bacteria in 2019, most in In recent years, bacterial resistance to antibiotics has been increasing glob- sub-Saharan Africa. Of these, about 1.3 million died due to the direct effects ally, threatening the health security of both humans and animals. In 2019, of resistant bacteria. It has been predicted that if the current trend of an- the World Health Organization (WHO) declared that antibiotic resistance tibiotic resistance continues, at least ten million people will die globally in was one of the top ten health threats facing the world1 and in July 2022, the 2050 due to antibiotic resistant bacteria, and global gross domestic prod- European Commission (EC) similarly declared that antibiotic resistance was uct (GDP) will decrease by 2-3.5% 6 . The COVID-19 pandemic and conflicts one of the top three health threats to European Union (EU) member states . 2 between countries are likely to accelerate this trend. The reduction in Gross 1 WHO. Ten threats to global health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. 2 European Commission. HERA factsheet-HEALTH UNION: Identifying top 3 priority health threats. https://health.ec.europa.eu/publications/hera-factsheet-health-union-identifying-top-3-priority-health-threats_en. 3 https://www.fao.org/antimicrobial-resistance/background/what-is-it/en/ 4 The Lancet, nóvember 2022. Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)02185-7/fulltext. 5 The Lancet, janúar 2022. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2821%2902724-0. 6 Review on Antimicrobial Resistance, Tackling drug-resistant infections globally. https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 11 Domestic Product (GDP) will primarily result from increased healthcare costs due to limited treatment options for patients with infections caused by antibiotic-resistant bacteria7, 8. Many international organisations, such as the United Nations (UN) 9, WHO10, the World Organisation for Animal Health (WOAH)11, the European Centre for Disease Prevention and Control (ECDC)12, the Organisation for Economic Co-operation and Development (OECD)13 and the European Food Safety Authority (EFSA)14 have also expressed great con- cern about the increasing spread of antibiotic resistance and urged action. 7 ECDC. The bacterial challenge: time to react. https://www.ecdc.europa.eu/sites/default/files/ media/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_React.pdf. 8 OECD. Stemming the Superbug Tide. https://www.oecd.org/health/stemming-the-superbug- tide-9789264307599-en.htm. 9 The United Nations General Assembly, 71st session. http://www.un.org/pga/71/event-latest/ high-level-meeting-on-antimicrobial-resistance/. 10 WHO. Sixty-eighth World Health Assembly 2015. 11 World Organization for Animal Health 2023. https://doc.woah.org/dyn/portal/digidoc.xhtml?statelessToken=mASJwRxf8hf20kfBAKEZpe dOWnC5F0qhnrW9d1VgCpo=&actionMethod=dyn%2Fportal%2Fdigidoc.xhtml%3AdownloadAttachment. openStateless. 12 ECDC. Antimicrobial resistance. https://www.ecdc.europa.eu/en/antimicrobial-resistance. 13 OECD. Antimicrobial Resistance. https://www.oecd.org/health/antimicrobial-resistance.htm?utm_campaign=ELS%20Newsletter%20 November%202023&utm_content=AMR-project-page&utm_term=els&utm_medium=email&utm_ source=Adestra. 14 EFSA. Antimicrobial resistance. https://www.efsa.europa.eu/en/topics/topic/antimicrobial-resistance. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 12 In June 2023, the EC published a detailed report containing recommendations food, and therefore all nations must contribute with coordinated actions. for actions against antibiotic resistance in the spirit of "One Health," which refers to actions concerning humans, animals, food, and the environment15. The An interdisciplinary working group of the Ministry of Health (HRN), the Minis- report stated that all countries should aim to reduce the total use of antibiotics try of Food, Agriculture and Fisheries (MAR), and the Ministry of the Environ- in humans by at least 20% by 2030 and by 50% in animals. These recommenda- ment, Energy, and Climate (URN) was appointed in December 2022. The group tions emphasise the need for member states to take action before the problem presented proposals for a five-year action plan (2025-2029) on the spread becomes insurmountable. of antibiotic resistance in Iceland in January 2024. The proposals were sub- sequently approved by the government in February of the same year as the It is crucial to preserve the effectiveness of the antibiotics currently on the government's action plan on the matter 17. market because, at this time, few new antibiotics are in the research and/ or approval process. WHO has concluded that since new antibiotics are not The action plan is based on numerous activities that need to be undertaken, as on the horizon, comprehensive measures must be taken to address the in- detailed later in this document. They are prioritised, costs estimated, responsi- crease in antibiotic resistance16. ble stakeholders specified, and their timeframes set. To achieve success in the global fight against antibiotic resistance, it is essential The working group is also responsible for monitoring the implementation that all nations cooperate because the spread does not respect borders. Anti- and progress of the action plan and will publish a report at least annually biotic resistance spreads between countries with humans, animals, feed, and (monitoring and evaluation). 15 European Commission. Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach. https://health.ec.europa.eu/publications/council-recommendation-stepping-eu-actions-combat-antimicrobial-resistance-one-health-approach_en. 16 WHO. Global shortage of innovative antibiotics fuels emergence and spread of drug-resistance. https://www.who.int/news/item/15-04-2021-global-shortage-of-innovative-antibiotics-fuels-emergence-and-spread-of-drug-resistance. 17 https://www.stjornarradid.is/efst-a-baugi/frettir/stok-frett/2024/02/22/Ny-adgerdaaaetlun-heilbrigdisradherra-til-ad-sporna-vid-utbreidslu-syklalyfjaonaemis/ July 2024 National Action Plan (NAP) on Antimicrobial Resistance 13 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 14 The six actions of the Action Plan The duration of the action plan is five years (2025–2029) and it consists of For each action, objectives are set to be achieved, and for each objective, the following six actions (see appendix 1, p.31): specific activities are identified that need to be undertaken (see p.26). For each objective, output indicators and benchmarks are also specified. Re- sponsible stakeholders are identified for each activity and their timeframes and priority set. Most of the activities are long-term projects that need to be 1 Promote targeted and prudent use of antibiotics in humans reviewed regularly, or at least every five years. It should be noted that work and animals (see p.15). on some of the activities is already partially or fully underway. The work cur- rently in progress is specified in the appendix 1. In a special section later in 2 Limit the spread of antibiotic resistance through information this document the cost estimates for individual activities during the period dissemination, education, and prevention (see p.17). 2025 to 2029 is discussed (p.24) as well as in appendix 1. 3 Improve knowledge of antibiotic resistance through monitoring and scientific research (see p.19). 4 Contain the spread of antibiotic resistance through intervention measures (see p.21). 5 Increase participation in international cooperation on actions against antibiotic resistance (see p.22). 6 Ensure coordination and management of actions against antibiotic resistance for the future (see p.21). July 2024 National Action Plan (NAP) on Antimicrobial Resistance 15 1. Promote targeted and prudent use of antibiotics in humans and animals  Excessive and/or imprudent use of antibiotics in humans and animals is con- sidered one of the main risk factors for the emergence and spread of antibi- 1.1. Enhance and develop electronic records and monitoring otic resistant bacteria. Antibiotic resistance arises due to genetic changes in of antibiotic prescriptions in humans. the bacteria and can, in many cases, spread from one bacterium to another.

1.2 — Promote reduced and prudent use of antibiotics in humans

1.2. Promote reduced and prudent use of antibiotics in humans Activities that promote the targeted and prudent use of antibiotics in humans through quality development and creation of guidelines. and animals are therefore an important part of the action plan (see appendix 1, p.31). Registration of antibiotic use and easy access to the data is essential 1.3. 1.3. Enhance and develop electronic records and monitoring for undertaking activities that promote improved usage. Therefore, activities of antibiotic prescriptions in animals. related to the registration of antibiotic use, creation of databases, and data monitoring are significantly prominent in this action. Activities related to the

1.4 — Promote prudent use of antibiotics in animals through

1.4. Promote prudent use of antibiotics in animals through development of guidelines and quality improvement are also key elements to quality development and creation of guidelines. achieving success, both in primary care, nursing homes, and hospitals, as well as among physicians and veterinarians in independent practicies. Education for the public and professionals about the use of antibiotics also plays an im- portant role in reducing and improving usage. The educational aspect of the action plan is specifically discussed on p.19. In the first action, the following four objectives are set to reduce and im- prove antibiotic use in both humans and animals: July 2024 National Action Plan (NAP) on Antimicrobial Resistance July 2024 National Action Plan (NAP) on Antimicrobial Resistance 16 A total of 22 activities are specified to achieve the above mentioned objec- tives. Out of these, 16 activities are in priority group one and six in priority group two, with none in priority group three. The total cost of all activities in action one for the period 2025-2029 is estimated at around 606 million ISK, although it varies somewhat between years. The responsible stakeholders for the 13 activities under objectives 1.1 and

1.2 — (antibiotic use in humans) are the Directorate of Health (EL) (seven), the

1.2 (antibiotic use in humans) are the Directorate of Health (EL) (seven), the Development Centre of the Icelandic Primary Health Care (ÞÍH) (three), the Chief Epidemiologist (SVL) (two), and Landspítali, the National University Hospital of Iceland (LSH) (one activity). Additionally, numerous other stake- holders are involved, including hospitals, other healthcare institutions, HRN, and the Association of Welfare Service Companies (SVF). The responsible stakeholders for the nine activities under objectives 1.3 and

1.4 — (antimicrobial use in animals) are Icelandic Food and Veterinary Authority

1.4 (antimicrobial use in animals) are Icelandic Food and Veterinary Authority (MAST) (seven), MAR (one), and HRN (one activity). Other stakeholders are also involved in the implementation of several of the activities in action one. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 17 2. Limit the spread of antibiotic resistance through information dissemination, education, and prevention  The core of the action plan involves initiatives aimed at reducing and improving the use of antibiotics, enhancing hygiene practices (infection prevention and 2.1. Increase public knowledge about antibiotic resistance, the use control), and preventing infections through other means such as vaccinations. of antibiotics, and infection prevention. To achieve this, it is essential to educate and inform the general public, health- care professionals, welfare service staff, veterinarians, and food producers 2.2. Increase the knowledge of healthcare workers and welfare service about the importance of prudent antibiotic use and the significance of infection staff about antibiotic resistance, the use of antibiotics, and infection control measures. prevention. Public health measures among the general population and various vaccinations

2.3 — Increase the knowledge of veterinarians about antibiotic resistance,

2.3. Increase the knowledge of veterinarians about antibiotic resistance, reduce the incidence of common respiratory and gastrointestinal infections, the use of antibiotics, and infection prevention. thereby reducing the use of antibiotics and consequently the spread of anti- biotic-resistant bacteria. Education of the public about preventive measures

2.4 — Increase the knowledge of food producers and other food

2.4. Increase the knowledge of food producers and other food and participation in vaccinations against pathogens such as pneumococci, H. companies about antibiotic resistance, the use of antibiotics, influenzae type b, influenza (common causes of respiratory infections), and and infection prevention. rotavirus (common cause of acute gastrointestinal infections in children) plays a crucial role in reducing disease burden in society and spread of antibiotic resistant bacteria. 2.5. Reduce the likelihood of infections among the public in the community. Additionally, hygiene measures are crucial in preventing the spread of antibi- otic resistant bacteria among animals, reducing the likelihood of transmission between humans and animals, and minimising the risk of food contamination. Under action two, which includes activities involving information dissemina- tion, education, and prevention, the following five objectives are set to limit the spread of antibiotic resistant bacteria (see appendix 1, p.31): July 2024 National Action Plan (NAP) on Antimicrobial Resistance July 2024 National Action Plan (NAP) on Antimicrobial Resistance 18 A total of 18 tasks are specified in action two in order to achieve the above mentioned objectives. Of these, five are in priority group one, eleven in prior- ity group two, and two in priority group three. The total cost of the activities for the period 2025–2029 is estimated to be around 196 million ISK, although it varies somewhat between years. The responsible stakeholders for the 18 activities under action two are SVL (seven), MAST (six), HRN (three), ÞÍH (one), and the Primary Health Care of the Capital Area (HH) (one activity). Numerous other stakeholders are also involved in action two. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 19 3. Improve knowledge of antibiotic resistance through monitoring and scientific research  In order to implement the most effective and efficient measures against antibi- otic resistance at any given time, it is necessary to obtain scientific knowledge 3.1. Harmonise the notification and registration requirements for all about the emergence and spread of resistant bacteria and to gain the best un- antibiotic resistant bacteria according to One Health approach. derstanding of their distribution through monitoring in humans, animals, food, and the environment. 3.2. Improve knowledge of the spread of antibiotic resistant bacteria in humans. The results of monitoring and scientific research provide a necessary basis for assessment and comparison and are also important for evaluating the need for

3.3 — Improve knowledge of the spread of antibiotic resistant bacteria in

3.3. Improve knowledge of the spread of antibiotic resistant bacteria in and the success of intervention measures. animals and food. Regulation No. 221/2012, on reporting for infection control, specifies mandatory no-

3.4 — Improve knowledge of the spread of antibiotic resistant bacteria

3.4. Improve knowledge of the spread of antibiotic resistant bacteria tifications for certain resistant bacteria detected in humans. A similar notification and antibiotic residues in the environment. obligation applies to food and feed, referencing the aforementioned regulation, but it is not in place for antibiotic resistant bacteria detected in animals and the environment. It is important that comparable regulations apply to these as well. 3.5. Strengthen basic research on antibiotic resistance according to One Health approach. Whole genome sequencing (WGS) of bacteria is currently considered the best method for studying the origin and spread of antibiotic resistant bacteria but 3.6. Enhance and coordinate whole genome sequencing of antibiotic has not been systematically used for investigating antimicrobial resistance resistant bacteria. (AMR) in Iceland. It is anticipated that in the coming years, the use of WGS for investigating particular AMR will be partially mandated within the EU. There- fore, WGS needs to be officially implemented for laboratory investigations of antibiotic resistant bacteria in Iceland. In order to improve knowledge of antibiotic resistance through monitoring and scientific research, six objectives are set (see appendix 1, p.31): July 2024 National Action Plan (NAP) on Antimicrobial Resistance 20 A total of 17 activities are specified to achieve the above mentioned objec- tives. Of these, ten are in priority group one, six in priority group two, and one in priority group three. The total cost of all activities in this action for the years 2025–2029 is estimated to be around 768 million ISK, although it varies somewhat between years. The main responsible stakeholders for the activities are MAR (six), SVL (three), UST (three), HRN (two), MAST (two), and LSH (one activity). Numerous other stakeholders are also involved in action three. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 21 4. Contain the spread of antibiotic resistance through intervention measures  Antibiotic resistant bacteria can be found in samples obtained from hu- mans, animals, food, or the environment. It is important that in such cases, 4.1. Ensure appropriate responses when certain resistant bacteria guidelines are available to determine whether specific treatments and/or in humans are detected. measures are needed to eradicate these resistant bacteria and/or prevent their spread. 4.2. Ensure appropriate responses when certain resistant bacteria in animals are detected. In order to contain the spread of antibiotic resistance through intervention measures, five objectives are set in action four (see appendix 1, p.31):

4.3 — Ensure appropriate responses when certain resistant bacteria

4.3. Ensure appropriate responses when certain resistant bacteria in food are detected.

4.4 — Treat wastewater appropriately in order to minimise the spread

4.4. Treat wastewater appropriately in order to minimise the spread of certain antibiotic resistant bacteria. A total of seven activities are specified to achieve the above mentioned ob- jectives. Of these, three are in priority group one and four in priority group two. The total cost of the activities for the period 2025–2029 is estimated to be 4.5. Ensure appropriate responses when certain resistant bacteria around 50 million ISK. or antibiotic residues are detected in the environment. The responsible stakeholders for the seven activities under action four are MAST (three), UST (two), SVL (one), and URN (one activity). Additionally, various other stakeholders are involved in action four. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 22 5. Increase participation in international cooperation on actions against antibiotic resistance  Since the spread of both antibiotic susceptible and antibiotic resistant bac- teria does not respect borders, international cooperation is of utmost impor- 5.1. Strengthen cooperation with institutions of the European Union. tance in the battle against AMR. Most nations have published or are working on creating National Action Plans against antibiotic resistance following the 5.2. Strengthen cooperation with international organisations. guidelines of WHO. Additionally, international cooperation provides access to research collaborations and funding for research domestically, which facili-

5.3 — Strengthen Nordic cooperation

5.3. Strengthen Nordic cooperation. tates the implementation of various tasks in this action plan. In order to increase participation in international cooperation, three objec- tives are set in action five (see appendix 1, p. 31): A total of ten activities are specified to achieve the above mentioned objectives. Of these, nine are in priority group one and one in priority group three. The total cost of the activities for the period 2025–2029 is estimated to be around 145 million ISK. The responsible stakeholders for the ten activities under action five are HRN (four), SVL (three), MAST (two), and MAR on behalf of the Institute for Experi- mental Pathology at Keldur, University of Iceland (Keldur), for activity 5.1.5 (one activity). Additionally, several other stakeholders are involved in the activities in action five. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 23 6. Ensure coordination and manage- ment of actions against antibiotic resistance in Iceland for the future  To ensure good coordination and implementation of the activities specified in the plan, it is important that an interdisciplinary group of experts will be 6.1. Ensure the implementation and execution of activities against active at all times. This group will have the role of monitoring the imple- antibiotic resistance in the near future. mentation and progress of the action plan and making recommendations for changes if necessary. Additionally, the group needs to monitor cost es- timates and progress in cooperation with the responsible stakeholders (see The responsible stakeholder for this objective is HRN, but MAR, and URN the section on indicators on. P.30). also participate in the coordination and management. The interdisciplinary working group that proposed the action plan against The cost of action six is estimated to be around 27 million ISK for the period antibiotic resistance to the government of Iceland has been provided the 2025-2029. Most of the cost will be borne by HRN, but certain expenses will task of implementing the plan and monitoring its progress ("monitoring and also be covered by the MAR, and URN (see appendices 2.2 and 2.3, p.52). evaluation plan"). In this action, there is one objective (see appendix 1, p.31): July 2024 National Action Plan (NAP) on Antimicrobial Resistance 24 Cost Estimates of Activities Responsible stakeholders for individual activities estimated the total costs of their activities assigned to them within each action rather than the cost of each activity. Results of the cost estimates can be seen in appendix 2 on p.52. Costs are divided into basic and additional costs. Basic costs refer to the fund- ing that responsible stakeholders are already allocating to specific activities, while additional costs are the extra funding needed to carry out or complete specific activities over the five-year period of the plan. The cost estimates do not account for changes in price levels between years. Given the considerable uncertainty about the cost of individual activities in the coming years, it will be necessary to review the cost estimates at least annually. This review will be the responsibility of the working group discussed in action six on p.23. As stated in appendix 2 on p.51, the total cost of all actions against antibiotic resistance over a five year period is expected to be around 1.8 billion ISK. Of this amount, additional cost is estimated to be around 1.2 billion ISK. The largest cost items in the plan are associated with activities focusing on promoting more targeted and prudent use of antibiotics and activities aim- ing at various types of monitoring and scientific research. Although the cost of implementing the action plan is substantial, it can be as- serted that keeping the spread of antibiotic-resistant bacteria under control will be significantly cost-effective, as stated in chapter on introduction. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 25 Responsible Stakeholders for Activities The responsible stakeholders for each activity are specified in the action plan (see appendix 1, p.31.). They are responsible for implementing the activities within the specified time frame and for assessing the costs, both basic and additional costs. In many cases, the responsible stakeholders will not carry out the implementation of the projects themselves but will ensure that they are carried out by other stakeholders. Other stakeholders in collaboration with the responsible stakeholders are also involved in most of the activities and are specified in the plan. This does not exclude the involvement of others if deemed necessary. Of the 75 tasks specified in the action plan, 41 is the responsibility of HRN and its institutions, 28 are the responsibility of MAR and its institutions, and six are the responsibility of URN. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 26 Prioritisation of Activities The activities in the action plan are prioritised into three categories, It is most important to promptly undertake the activities with the highest pri- with category one encompassing the most urgent one to be implemented. ority, but the aim is to carry out all activities according to the action plan. Only through extensive One Health approach can satisfactory results be obtained. The prioritisation considers the following factors: Of the 75 activities specified in the action plan, 44 are in priority group one, 27 in group two, and four in group three. • Is the activity likely to be effective in preventing the spread Of the 44 activities in priority group one, 25 are the responsibility of HRN of antibiotic resistant bacteria? and its institutions, 16 are the responsibility of MAR and its institutions, and three are the responsibility of the URN. • Is it likely that the activity will be implemented within the next two years, five years, or later? Of the 27 activities in priority group two, 14 are the responsibility of HRN and its institutions, ten are the responsibility of MAR and its institutions, and • Has the project already started but not yet been completed? three are the responsibility of the URN. Of the four activities in priority group three, two are the responsibility of • Is the project defined in a regulation but has not yet been implemented? HRN and two are the responsibility of MAST. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 27 Time frame of Activities Indicators of the Action Plan The government action plan is a five year plan covering the years 2025–2029. Two types of indicators are set to measure the success of the action plan: out- In appendix 1 the status of the activities that are already partially or fully put indicators and outcome indicators. The guidelines from WHO18 on moni- underway can be seen. toring and evaluating action plans against antibiotic resistance are used as a reference and adapted to Icelandic conditions. The One Health policy of EU is The action plan and individual activities will be regularly reassessed, or at also considered, which encourages member countries to reduce antibiotic use least every five years. It is clear that some of the activities are short term in humans by at least 20% by 2030 and by 50% in animals19. projects that hopefully can be completed in a few years, but most of the ac- tivities are long term initiatives that involve changing work practices for the Output Indicators future. The time frames for individual activities can be seen in appendix 1. Output indicators are indicators for each objective which assess whether the objectives of the action plan have been achieved (see appendix 1). In ad- dition to output indicators, progress benchmarks are set for each objective, which should be reached by 2030. For some objectives, particularly those related to the environment, it is not possible to set indicators and benchmarks due to a lack of baseline infor- mation. In such cases, emphasis will be placed on gathering data and subse- quently developing guidelines. Output indicators can be added later to the action plan in these instances. 18 WHO. Monitoring and evaluation of the global action plan on antimicrobial resistance. https://iris.who.int/bitstream/handle/10665/325006/9789241515665-eng.pdf?ua=1. 19 ESB. Council recommendation on stepping up EU acitons to combat antimicrobial restistance in a One Health approach. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 28 Outcome indicators Outcome indicators measure the overall success of the action plan. Outcome Table 1. Proportion of selected antibiotic resistant bacteria (%) in humans in 2022 and goals for 2029. indicators are divided into indicators for humans, animals, and food, but at this time, it is difficult to establish outcome indicators for the environment due to Bacteria Resistance Samples 2022 2029 limited information on the spread of antibiotic resistant bacteria in the envi- ronment in Iceland. Staphylococcus aureus Methicillin (MRSA) Invasive 1,1% <2% E. coli ESBL Invasive 9,8% <15%* The outcome indicators set in this action plan are based on those published in the EU's One Health policy17 but have been adapted to Icelandic conditions. The Carbapenemase All samples 0,0% 0% action plan aims for a 20% reduction in antibiotic use in humans by 2029 com- producing pared to 2022. However, it is challenging to aim for a 50% reduction in animal Klebsiella pneumoniae Carbapenemase All samples 0,0% 0% use since usage in Iceland is already low and lower than in almost all European producing countries. Streptococcus pneumoniae Penicillin Invasive 28,6% <20% resistance (R**) Outcome indicators for humans Penicillin and Invasive 28,6% <20% erythromycin Outcome indicators for humans address changes in the resistance rates of resistance certain bacteria identified in humans, changes in the use of specific antibiotic Reduced penicillin All samples 41,0% <25% classes, and changes in participation in certain vaccinations that prevent var- resistance (I***+R) ious respiratory infections, thereby reducing the use of antibiotics. H. influenzae Resistance for All samples 23,0% <20% amoxicillin+ clavulanic * ESBL resistance has been increasing in recent years. Therefore, 20% reduction is unlikely as proposed by the EUl17. **Resistant ***Intermediate resistance July 2024 National Action Plan (NAP) on Antimicrobial Resistance 29 Table 2. Antibiotic use in humans (DID) in 2022 and goals for 2029. Table 3. Proportion of humans fully vaccinated (%) in 2022 and goals for 2029. Antibiotic use in humans 2022 2029 Vaccinations 2022 2029 Total ATC J01 (sales) 19,5 15 Pneumococci - children 92% 92% Total ATC J01 community (prescriptions) 17,55 14 Pneumococci - 60+ years 35% 70% Total ATC J01 hospitals/ 1,1 1 Influenza - 60+ years 55% 70% institutions (sales) COVID-19 - 60+ years 73% 70% Proportion of antibiotics in „Access“ >80% >80% group WHO („AWaRe“) Influenza - children 30% 70% Tetracyclines community (ATC J01A) 4,5 2,5 (prescriptions) Third generation cephalosporins 0,18 0,15 hospitals/institutions (ATC J01DD) (sales) July 2024 National Action Plan (NAP) on Antimicrobial Resistance 30 Outcome indicators for animals and food Outcome indicators for animals and food address changes in the resistance Table 4. Proportion of selected antibiotic resistant bacteria (%) in animals and food in 2022 rates of certain bacteria identified in and on animals and food, along with and goals for 2029. changes in the use of specific antibiotics in animals. Bacteria Resistance Samples 2022 2029 Staphylococcus Methicillin (MRSA) Pigs, swab samples 0% 0% aureus at slaughtering E. coli ESBL/AmpC All samples <1% <1% producing (except up-regulated chromosomal AmpC) Carbapenemase All samples 0% 0% producing Table 5. Antibiotic use in animals (mg/PCU*) in 2022 and goals for 2029. Antibiotic use in animals 2022 2029 Total (tablets) (sales) 5,3** <4 Group B (AMEG group) 0,1% <0,5% Group D (AMEG group) >82% >90% * PCU: Estimated weight of lifvestock each year ** According to the EMA report on the sale of antibiotics for animals in 2022, the recorded sale was about 0.6 tons of active substances (including tablets), and the PCU was 140.2. This gives about 4.8 mg/PCU. However, it has been found that the actual sale was closer to 0.75 tons of active substances, making the real figure 5.3 mg/PCU July 2024 National Action Plan (NAP) on Antimicrobial Resistance 31 Appendices July 2024 National Action Plan (NAP) on Antimicrobial Resistance 32 1. Action and Implementation Plan Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

1.1

1.1 Enhance and develop 1.1.1 The proportion of Standardised recording Electronic recording EL SVL, health 1 2025 2029 electronic records and antibiotic prescriptions of antibiotic prescrip- of antibiotic prescrip- institutions, monitoring of antibiotic in humans recorded in tions for inpatients in tions in all hospitals hospitals prescriptions in humans. central databases. Infor- hospitals not in place. established, and data is mation is accessible and transferred electronical- Output indicator: published in monitoring ly to central databases 1. Promote targeted and prudent use The proportion of antibiotic reports. at EL. prescriptions in humans

1.1.2

1.1.2 Improve the record- Indications are not Indications for antibiotic EL SVL, health 2 2025 2026 recorded in central data- ing of indications for an- directly recorded in the prescriptions accessible institutions bases. Information tibiotic prescriptions in electronic medication in the electronic systems accessible and published of antibiotics in humans and animals the electronic databases administration systems of hospitals/institutions in monitoring reports. of hospitals, and transfer of hospitals/institutions. and in the central data- the information to cen- Indications (diagnoses) base at EL. Benchmark: tral databases at EL. are recorded in the >90% of all antibiotic electronic health record, prescriptions in humans which is not directly con- are recorded in the central nected to the medication database, and data administration systems. accessible in 2029.

1.1.3

1.1.3 Set up a dashboard/ Dashboard/data visual- Dashboard/data visu- EL SVL 2 2025 2029 data visualisation for an- isation not available in alisation for antibiotic tibiotic prescriptions for the electronic systems of prescriptions available doctors in the electronic hospitals. in hospital electronic systems of hospitals. systems. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 33 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

1.1.4

1.1.4 Implement and Electronic recording and Electronic recording of EL ÞÍH, SVL, SFV, health 1 2027 2028 introduce electronic transfer of information on antibiotic prescriptions institutions. recording of antibiotic antibiotic prescriptions in all nursing homes prescriptions in all in nursing homes to the implemented, and nursing homes. Data on central databases at EL prescription informa- prescriptions transferred not in place except where tion transferred to the to the central databases the prescription portal medication database at at EL. is used. Many nursing the EL. homes have adopted the eMed system, but data not transferred to EL. 1. Promote targeted and prudent use

1.1.5

1.1.5 Start recording Indications not recorded Recording of indications EL ÞÍH, SVL, SFV, health 2 2027 2028 indications for antibiotic in the electronic medica- implemented in the institutions. prescriptions in the elec- tion administration sys- electronic systems of tronic systems of nursing tems of nursing homes. nursing homes, and the of antibiotics in humans and animals homes, and transfer the information accessible information to the central centrally at the EL. databases at the EL.

1.1.6

1.1.6 Set up a dashboard/ Dashboard/data visual- Dashboard/data visu- EL SFV, SVL. 2 2027 2028 data visualisation for isation not available in alisation for antibiotic antibiotic prescriptions nursing homes. prescriptions available in for doctors in nursing all nursing homes. homes.

1.1.7

1.1.7 Improve the record- Recording of indications Improved recording of ÞÍH 2 2025 2026 ing of indications for anti- is partially in place at antibiotic prescriptions biotic prescriptions in the all primary healthcare in primary healthcare. prescription database of centers but is used to primary healthcare with varying extents. Infor- detailed classification. mation is not transferred Information transferred centrally to the EL. to the central databases at the EL. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 34 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

1.1.8

1.1.8 Develop further Interactive presenta- Interactive presentation EL SVL, health 1 2026 2029 interactive presentation tion of drug statistics of drug statistics estab- institutions, of statistics on antibiot- is partially available at lished for all antibiotic hospitals. ic prescriptions. the EL for medications prescriptions. dispensed through the Prescription Portal.

1.1.9

1.1.9 Develop further the The annual report by the Establish the annual SVL MAST, UST, Medicine 1 2025 2029 annual report by the SVL SVL and stakeholders publication and institu- Agency, SVEID. and other stakeholders published annually. tional collaboration. on antibiotic use. 1. Promote targeted and prudent use

1.2

1.2 Promote reduced and 1.2.1 Enhance the devel- Antibiotic stewardship Antibiotic stewardship LSH Hospitals, SVL. 1 2025 2029 prudent use of antibiotics in opment and promotion implemented only at implemented at all major humans through enhanced of guidelines LSH (active only at the hospitals. quality development and on antimicrobial use Children's Hospital). creation of guidelines. and stewardship at of antibiotics in humans and animals larger hospitals. Output indicator: The proportion of defined 1.2.2 Enhance the devel- The development of Guidelines on antibiotic ÞÍH Öldrunarlæknar, SVL. 1 2025 2027 target groups with specified opment and dissemi- guidelines on antibiotic use in all nursing homes guidelines.The proportion nation of guidelines on use in nursing homes has in place. of health institutions with nursing homes on antibi- started. active antibiotic stewardship otic use and stewardship. programs.

1.2.3

1.2.3 Firmly establish the The Strama project ÞÍH will be entrusted the ÞÍH HRN, HH. 1 2024 2029 Strama project within the has been implemented in responsibility for the Benchmark: primary care and contin- all primary care centers activity to the future. >95% of defined target ue its development. except at the „Læknavakt“. groups with guidelines by the year 2029. >95% of 1.2.4 Encourage the de- Guidelines only in place Guidelines in place for SVL LSH, medical 1 2025 2028 health institutions with velopment of guidelines for primary healthcare defined groups of spe- associations. active antibiotic stewardship for antibiotic use among (Strama) and to some cialists outside hospitals programs. the groups of specialists extent for pediatricians. who prescribe antibiotics outside hospitals who the most. prescribe antibiotics the most. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 35 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

1.3

1.3 Enhance and develop 1.3.1 Implement and A central database has Central database MAST 1 2025 2026 electronic recording and introduce electronic been established but implemented and usage monitoring of antibiotic recording of antibiotic is not yet fully opera- introduced. prescriptions in animals. prescriptions in animals, tional. Introduction has and transfer prescription begun. Implementation Output indicator: information to central completed in the coming The proportion of anti- databases. weeks/months. biotic prescriptions in

1.3.2

1.3.2 Amend the regulation Regulation regarding the The regulation on the MAR MAST 1 2025 2026 animals recorded in central to mandate all records of obligation of recording obligation of recording databases. Information antibiotic prescriptions to has come into effect, but and implementation has accessible and published in be logged into the data- further details are need- taken effect. monitoring reports. base in the future. ed on how the recording 1. Promote targeted and prudent use should be implemented. Benchmark: >90% of antibiotic pre- 1.3.3 Enhance monitoring Monitoring not sufficient Information on antibiotic MAST 1 2025 2029 scriptions recorded in the by recording antibiotic at present. prescriptions for animals central database, and data prescriptions for animals available. of antibiotics in humans and animals accessible by the year 2029. in a central database.

1.3.4

1.3.4 Set up a dashboard/ Dashboard/data visual- Dashboard/data MAST 1 2025 2026 data visualisation for reg- isation not available in visualisation functional. ulatory authorities (MAST). the central database.

1.4

1.4 Promote prudent use 1.4.1 Prepare guidelines Guidelines not available. Guidelines available. MAST DÍ 1 2025 2027 of antibiotics in animals on antibiotic use in through enhanced quality animals. development and guidelines.

1.4.2

1.4.2 Implement regu- No regulation is currently A new regulation has HRN MAST, MAR. 1 2025 2025 lations on restrictions in place. Draft regulation come into effect. Output indicator: regarding veterinarians' was submitted to the Percentage of defined authority to prescribe MAR by the end of 2020. target groups with specified antibiotics. guidelines.

1.4.3

1.4.3 Set up a dashboard/ Dashboard/data visuali- The dashboard/data MAST 2 2026 2027 Benchmark: data visualisation in da- sation is not available. visualisation has been >95% of defined target tabases for veterinarians. implemented. groups with guidelines by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 36 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

1.4.4

1.4.4 Increase monitoring Monitoring of prescrip- Monitoring firmly MAST 1 2025 2029 of prescriptions and tions of specific drugs established. 1. Promote targeted and prudent use use of certain antibiot- has not been conducted. ics (Category B in the AMEG classification) and clarify veterinarians' exemptions to dispense of antibiotics in humans and animals antibiotics.

1.4.5

1.4.5 Increase dialogue Dialogue has begun, Regular informational MAST DÍ 1 2025 2029 between regulatory needs to be firmly meetings, at least authorities (MAST) and established. annually. veterinarians through regular formal and infor- mational meetings. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 37 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

2.1

2.1 Increase public 2.1.1 Conduct regu- A Nordic survey was Regular surveys SVL ÞÍH, LSH. 1 2025 2029 knowledge about antibi- lar surveys on public conducted in 2018. conducted. otic resistance, the use of knowledge of antibiotic antibiotics, and infection resistance, antibiotic use, prevention. and infection prevention, and assess the need for Output indicator: increased education. The current level of public

2.1.2

2.1.2 Increase education Limited content on web- Widespread, coordinated, SVL ÞÍH, HH, MAST, UST, 1 2025 2029 knowledge on antibiotic and information dissem- sites and social media and accessible informa- Medicines Agency. resistance, the use of 2. Limit the spread of antibiotic resistance through ination in the media and of primary healthcare tion available. antibiotics, and infection on social media, based (Heilsuvera), the EL, prevention. on survey results (see island.is, MAST and UST. 2.1.1). Share information This information is not Benchmark: with other institutions coordinated. Significant increase in such as the EL, MAST, knowledge by the year 2029. UST, and Heilsuvera. information dissemination, education, and prevention

2.1.3

2.1.3 Enhance educa- SVL publishes informa- Information in Iceland SVL MAST, UST, ÞÍH, LSH. 2 2025 2029 tion in connection with tion annually on the EL coordinated with infor- the annual awareness website. mation from WHO, FAO, campaign of WHO, FAO, WOAH, and ECDC. Annual WOAH, and ECDC during media and social media the week of November campaign (television, 18-24. online media).

2.1.4

2.1.4 Increase education No formal education in Standardised education ÞÍH Icelandic Association 2 2025 2026 for parents in infant place. available and actively of Local Authorities. health care and enhance disseminated. access to educational materials for daycare and parents.

2.1.5

2.1.5 Develop educational No formal education in Proposals for an educa- MAST SAF, The Icelandic 3 2027 2028 materials for tourists place tional project for foreign custom. about the uniqueness tourists available. of Iceland regarding antibiotic resistance and animal diseases. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 38 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

2.1.6

2.1.6 Increase public edu- Information and educa- Increased availability of MAST SVL 2 2025 2029 cation on the importance tion available from the educational materials, of origin of food, proper MAST. inc luding social media. food preparation and handling.

2.1.7

2.1.7 Education for the Some educational Education for those HH ÞÍH, SVL, LSH. 1 2025 2029 public on antibiotic use, materials available on the traveling abroad, e.g., on infection prevention, websites of the SVL and Heilsuvera (in connection 2. Limit the spread of antibiotic resistance through antibiotic resistance, and Heilsuvera, but do not with travel vaccinations), the risk of infection during cover antibiotic resistance is available. international travel. in relation to travel.

2.1.8

2.1.8 Introduce education No formal education on Formal education in HRN MRN, Icelandic 3 2025 2029 on infection prevention infection prevention and place in primary and Association of Local and antibiotic resistance antibiotic resistance in secondry schools. Authorities. in primary and secondary primary and secondary information dissemination, education, and prevention schools. schools.

2.2

2.2 Increase the knowledge 2.2.1 Conduct a survey No survey has been A survey conducted. SVL ÞÍH, LSH, EL. 1 2025 2026 of healthcare workers and to assess the knowledge conducted. welfare service staff about of healthcare profes- antibiotic resistance, the use sionals and welfare of antibiotics, and infection service staff on antibiotic prevention. resistance, antibiotic use, and infection prevention, Output indicator: and map out the need for Level of knowledge among increased education. healthcare professionals

2.2.2

2.2.2 Encourage Quality documents and Quality documents and SVL ÞÍH, LSH, healthcare 2 2026 2027 and welfare service staff increased education informal education avail- guidelines for healthcare institutions, SFV, HÍ. on antibiotic resistance, and formal training, for able. This varies among professionals and nurs- antibiotic use, and infection healthcare professionals groups of healthcare ing home staff updated prevention. and welfare service staff professionals and staff in and/or developed by the according to the results nursing homes. relevant institutions. Benchmark: of the survey (see 2.2.1). Significant increase in knowledge by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 39 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

2.2.3

2.2.3 Annual awareness SVL annually publishes Information coordinat- SVL MAST, UST, ÞÍH, LSH. 2 2025 2029 campaign in connec- information on the EL ed information from tion with the annual website. WHO and ECDC. Annual awareness campaigns of symposium by the SVL WHO and ECDC during the on antibiotic resistance. week of November 18–24. Healthcare institutions publish news and content on their own platforms. 2. Limit the spread of antibiotic resistance through

2.2.4

2.2.4 Analyse the cur- Current status unknown. Analysis, implementa- HRN University of Iceland, 1 2025 2026 riculum for healthcare tion, and recommen- HA, HVIN. professional‘s education dations for improved on antibiotic resistance, education in place. antibiotic use, and infection prevention, and information dissemination, education, and prevention provide recommenda- tions for improvements.

2.3

2.3 Increase the knowledge 2.3.1 Conduct a survey No survey has been Survey been conducted. MAST DÍ 2 2025 2025 of veterinarians about to assess the knowledge conducted. antibiotic resistance, the use of veterinarians on of antibiotics, and infection antibiotic resistance, an- prevention. tibiotic use, and infection prevention, and map out Output indicator: the need for increased The level of knowledge education. among veterinarians on

2.3.2

2.3.2 Increase education No formal education in Educational materials, MAST DÍ 2 2026 2029 antibiotic resistance, for veterinarians based place. guidelines, and quality antibiotic use, and infection on the survey results documents for veterinar- prevention. (see 2.3.1). ians available. Benchmark: Significant increase in knowledge by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 40 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

2.4

2.4 Increase the knowledge 2.4.1 Conduct a survey No survey been Survey been conducted. MAST Public Health 2 2026 2026 of food producers and to assess the knowledge conducted. Committees. other food companies on of food producers and antibiotic resistance, the use companies on antibiotic of antibiotics, and infection resistance, antibiotic use, prevention. and infection prevention, and map out the need for Output indicator: increased education. The level of knowledge 2. Limit the spread of antibiotic resistance through

2.4.2

2.4.2 Increase education No formal education in Educational materials MAST Public Health 2 2027 2029 among food producers and for food producers and place. available and targeted Committees. food companies on antibiot- companies based on the education provided. ic resistance, antibiotic use, survey results (see 2.4.1). and infection prevention. Benchmark: Significant increase in information dissemination, education, and prevention knowledge by the year 2029.

2.5

2.5 Reduce the likelihood of 2.5.1 Improve/maintain Participation in pneu- Improved participation SVL Primary Health 2 2025 2029 infections among the public participation of children mococcal vaccination in vaccinations and care, ÞÍH. in the community. and adults in vaccinations among children is good ensured access to the against pneumococci, H. but lower in influenza best vaccines. Output indicator: influenzae b, and influen- vaccination. Participation Epidemiology of specified in- za, as well as vaccinations in influenza among 60 fections known at all times. against other respiratory years+ is 40 to 50%. infections. Ensure access Benchmark: to the best vaccines avail- Significant reduction in able at any given time. specified infections by the year 2029. 2.5.2 Explore the possibil- Parents are entitled to Increased sick leave HRN FRN 2 2025 2026 ity of increasing sick leave at least 12 sick days per rights for parents/guard- rights for parents/guard- year due to children's ians due to children's ians due to children's illnesses, regardless of illnesses. illnesses. the number of children. Rights vary according to collective agreements. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 41 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

3.1

3.1 Harmonise the notifi- 3.1.1 Examine whether Regulation on recording A new and updated regu- HRN SVL 1 2025 2025 cation and registration re- Regulation No. 221/2012 and reporting of bacteria lation comes into effect. quirements for all antibiotic needs to be revised last revised in 2023. resistant bacteria according regarding which antibiotic to One Health approach. resistant bacteria in hu- mans should be subject to Output indicator: mandatory reporting and The status of recordings on which bacteria should specified antibiotic resistant be subject to mandatory bacteria. recording. 3. Improve knowledge of antibiotic resistance

3.1.2

3.1.2 Harmonise the Harmonised regulations Harmonised notification MAR URN, MAST, UST. 1 2025 2025 Benchmark: notification and recording are not in place. and recording require- Recordings of specified requirements for resistant ments. bacteria fully harmonised bacteria identified in hu- in 2025. mans, animals, food, feed, and the environment. through monitoring and scientific research

3.2

3.2 Improve knowledge of 3.2.1 Ensure standardised Guidelines are available, Laboratories performing LSH EL, SVEID. 1 2025 2026 the spread of antibiotic re- procedures/guidelines but the status of imple- susceptibility testing use sistant bacteria in humans. for the detection of mentation in laborato- the same procedures antibiotic resistant ries is unknown. Reports (EUCAST) and send re- Output indicator: bacteria in laboratories. on resistance rates are sults on resistance rates The spread of antibiotic-re- Summary reports only sent from the SVEID. to SVL. sistant bacteria among spec- should be sent at least ified groups of humans. annually to the SVL.

3.2.2

3.2.2 Update and harmon- Guidelines on screening Updated and harmonised SVL LSH, SAk, healthcare 2 2025 2029 Benchmark: ise guidelines on screen- for resistant bacteria in guidelines on screenings institurions, nursing The spread of antibiotic ing for resistant bacteria healthcare services were are available. Analyses of homes. resistant bacteria known in healthcare institutions, published by the resistant bacteria from among all specified groups hospitals, nursing homes, SVL in 2019. Laboratory all laboratories recorded by the year 2029. and private clinics. Results analyses of resistant electronically and sent of susceptibility tests for bacteria at LSH and SAk to SVL. The spread of specified bacteria are are already recorded resistant bacteria in recorded electronically electronically and sent healthcare institutions, and information sent to SVL. hospitals, and nursing electronically to the SVL. homes known. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 42 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

3.2.3

3.2.3 Update harmonised Guidelines for employ- New and updated guide- MAST SVL, LSH, ÞÍH, primary 1 2024 2025 guidelines on screening ees of pig farms regard- lines for employees in health care. resistant bacteria in ing MRSA in place. primary production. employees of production facilities.

3.2.4

3.2.4 Develop a plan for Sentinel screening not Plan on sentinel SVL ÞÍH, LSH, HRN. 2 2025 2029 sentinel screening for an- conducted. screening in place and tibiotic resistant bacteria implemented. in the community.

3.2.5

3.2.5 Update guide- Guidelines in place. Guidelines updated. SVL LSH, HH. 2 2025 2029 3. Improve knowledge of antibiotic resistance lines on screenings of immigrants and asylum seekers.

3.3

3.3 Improve knowledge of 3.3.1 Ensure the enforce- The regulation has not Regulations enforced. MAR MAST, Public Health 1 2025 2025 the spread of antibiotic ment of current Regu- been fully enforced due Committees. resistant bacteria in animals through monitoring and scientific research lation No. 1000/2018 on to a lack of funding. and food. monitoring of antibiotic resistance in food and Output indicator: animals. The spread of antibiotic resistant bacteria among 3.3.2 Introduce MRSA "MRSA monitoring has Implemented into MAR MAST 2 2025 2025 specified groups of animals monitoring in pigs in been funded by grants regulation. and in food in summary regulations. from the Antimicrobial reports. Resistance and Zoonosis Fund of MAR. Benchmark:

3.3.3

3.3.3 Publish regulations Monitoring in lambs Regulation implemented. MAR MAST 2 2025 2025 The spread of antibiotic on monitoring of has been funded by resistant bacteria among all ESBL/AmpC and indicator grants from the Antimi- specified groups of animals bacteria in lambs. crobial Resistance and and in food known by the Zoonosis Fund by MAR. year 2029.

3.3.4

3.3.4 Publish guidelines Guidelines on Guidelines in place. MAST MAR 3 2027 2029 on screening for antibiotic screening in foods resistant bacteria in other other than meat prod- foods, such as vegetables ucts are not in place. and seafood. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 43 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

3.4

3.4 Improve knowledge on 3.4.1 Publish guide- No guidelines or Guidelines in place. UST Public Health 1 2025 2029 the spread of antibiotic lines on screening and regular monitoring for Committees, HRN, resistant bacteria and monitoring of antibiotic surveillance in place. URN, MAST. antibiotic residues in the resistant bacteria in environment. the environment and at certain hot spots. Output indicator:

3.4.2

3.4.2 Monitoring of anti- Only one screening has Regular screenings on UST Public Health 1 2026 2029 Information on the spread of biotic resistant bacteria been conducted by MAST the spread of resistance Committees, HRN, specific antibiotic-resistant 3. Improve knowledge of antibiotic resistance in the environment. in 2019. in the environment have URN, MAST. bacteria and antibiotic resi- begun, both related dues in the environment. to company operating licenses and official Benchmark: monitoring. Not relevant. through monitoring and scientific research

3.4.3

3.4.3 Monitoring of Annual screening in Monitoring plan UST Public Health 2 2025 2029 antibiotic residues in the 3 to 5 sessions in accor- published and increased Committees, HRN, environment (watchlist dance with the European screening initiated. URN. monitoring). Union watchlist.

3.5

3.5 Strengthen basic 3.5.1 Establish the The antibiotic resistance The antibiotic resistance MAR HRN, URN. 1 2025 2026 research on antibiotic antibiotic resistance fund fund has secured financ- fund has secured financ- resistance according to One with secure financing, ing only for several years ing for the future. Health approach. and encourage scientists at a time. to conduct research on Output indicator: antibiotic resistance. The number of published peer-reviewed articles from Iceland on antibiotic resistance. Benchmark: Not relevant. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 44 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

3.6

3.6 Enhance and coordinate 3.6.1 Establish an official No official policy exists Strategic guidelines and HRN LSH, MAR, URN, SVL, 1 2025 2026 3. Improve knowledge of antibiotic resistance whole genome sequenc- and harmonised policy and funding is not se- prioritisation in place. MAST, UST, MATÍS. ing of antibiotic resistant for WGS of antibiotic cured. WGS is performed Costs for sequencing bacteria. resistant bacteria in at LSH/SVEID, MATÍS, and secured. humans, animals, food abroad. Costs are covered Output indicator: and the environment, by various companies and The proportion of WGS on and secure funding. partly from the Zoonosis through monitoring and scientific research selected antibiotic-resis- Fund. tant bacteria carried out in

3.6.2

3.6.2 Implement WGS The EU has published Procedures for WGS on MAR MAST, Keldur, LSH. 1 2026 2027 Iceland in Iceland. in monitoring, accord- that starting from 2028, antibiotic resistant ing to EU Regulations monitoring of antibi- bacteria implemented. Benchmark: 1000/2018. otic resistance in food All WGS of antibiotic resis- and animals should be tant bacteria performed in conducted using WGS. Iceland by the year 2029. Iceland has not yet developed a strategy on how to comply with this. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 45 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

4.1

4.1 Ensure appropriate 4.1.1 Update and expand Guidelines from the SVL Harmonised guide- SVL LSH, SAk, ÞÍH. 1 2025 2029 responses when certain guidelines on eradication from 2019 on screening lines on intervention resistant bacteria in humans treatment, disinfection, and actions in healthcare measures both within are detected. and contact tracing institutions are available and outside healthcare both within and outside (https://island.is/sykin- institutions, hospitals, Output indicator: healthcare institutions, gavarnir-heilbrigdisth- and nursing homes. The proportion of defined hospitals, and nursing jonusta/leidbeiningar). target groups with specified homes for specific resis- They are also included in 4. Contain the spread of antibiotic resistance guidelines. tant bacteria. the LSH quality manual (SVEID-LSH). Benchmark: >95% of defined target groups with guidelines by the year 2029. through intervention measures

4.2

4.2 Ensure appropriate 4.2.1 Develop guidelines Guidelines not in place. Guidelines puiblished. MAST DÍ, 2 2027 2027 responses when certain on the treatment of pets resistant bacteria in animals identified with specific are detected. resistant bacteria. This includes disinfection and Output indicator: contact tracing. The proportion of defined target groups with specified 4.2.2 Develop guidelines Guidelines not in place. Guidelines published for MAST DÍ, BÍ, MAR. 2 2025 2027 guidelines. on the treatm ent of defined animal species. food producing animals Benchmark: identified with specific >95% of defined target resistant bacteria. This groups with guidelines by includes disinfection and the year 2029. contact tracing. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 46 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

4.3

4.3 Ensure appropriate 4.3.1 Develop guidelines Guidelines not in place. Guidelines published. MAST MAR, SVL. 1 2025 2028 responses when certain on the handling of food resistant bacteria in food and other consumer are detected. goods when certain resistant bacteria are Output indicator: detected, including The proportion of defined disinfection and contact target groups with specified tracing. 4. Contain the spread of antibiotic resistance guidelines. Benchmark: >95% of defined target groups with guidelines by the year 2029. through intervention measures

4.4

4.4 Treat wastewater 4.4.1 Wastewater treat- Many wastewater treat- The 30 largest urban URN Local communities, 1 2025 2029 appropriately in order to ment in Iceland complies ment facilities across the areas in the country Public Health minimise the spread of with the provisions of country do not comply have initiated measures Committees, HRN, certain antibiotic resistant laws and regulations. with the provisions of to improve wastewater MAST, UST. bacteria. laws and regulations. treatment. Output indicator: The proportion of defined urban areas that have initi- ated measures to improve wastewater treatment. Benchmark: >95% of defined urban areas have initiated measures by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 47 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

4.5

4.5 Ensure appropriate 4.5.1 Develop guidelines Guidelines not in place. Guidelines published. UST Public Health 2 2025 2028 responses when certain on actions when resistant Committees, HRN, 4. Contain the spread of antibiotic resistance resistant bacteria or antibi- bacteria are detected in URN, MAST. otic residues are detected wastewater/environment. in the environment.

4.5.2

4.5.2 Develop guide- Guidelines not in place. Guidelines published. UST Public Health 2 2025 2028 lines on actions when Committees, Output indicator: antibiotic residues HRN, URN, MAST, The proportion of defined through intervention measures are detected in the Medicines Agency. target groups with specified environment. guidelines. Benchmark: >95% of defined target groups with guidelines by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 48 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

5.1

5.1 Strengthen cooperation 5.1.1 Maintain and Cooperation and partic- Cooperation and par- SVL SVEID, Infection 1 2025 2029 with institutions of the strengthen cooperation ipation are in place. SVL ticipation satisfactory. control Department European Union. with ECDC on antibiotic is the national contact Information distributed of LSH, HRN. use and resistance. point with ECDC, and the to relevant domestic Output indicator: SVEID is the reference stakeholders. Measurement and assess- laboratory. ment of Iceland's partic-

5.1.2

5.1.2 Increase Iceland's Iceland is a participant Additional funding ob- HRN SVL, MAST, UST, LSH, 1 2025 2029 ipation in international participation in various in the EU project on tained for actions related ÞÍH, Keldur. cooperation. The proportion 5. Increase participation in international cooperation collabor ative projects, actions against antibiotic to antibiotic resistance. of projects and groups relat- such as Joint Action resistance and infections Increased knowledge and ed to antibiotic resistance in projects on antibiotic in the healthcare system more effective monitor- which Iceland participates. resistance and use. (JAMRAI-2). ing and measures against antibiotic resistance. Benchmark: Full participation in projects 5.1.3 Strengthen coopera- Cooperation and par- Cooperation and partic- HRN Medicines Agency, 1 2025 2029 and groups related to tion with EMA, especially ticipation are in place ipation satisfactory. En- hospitals, health on actions against antibiotic resistance antibiotic resistance by the regarding the ensured (Medicines Agency and sured supply of common institutions, SVL, year 2029. supply of antibiotics and MAST). antibiotics in Iceland MAR, MAST. access to new antibiotics. and good access to new antibiotics.

5.1.4

5.1.4 Maintain and Cooperation and partici- Cooperation and par- MAST MAR 1 2025 2029 strengthen cooperation pation are in place. MAST ticipation satisfactory. with EFSA. is the national contact Information distributed point with EFSA. to relevant domestic stakeholders.

5.1.5

5.1.5 Maintain the Cooperation and Cooperation and par- MAR Keldur 1 2025 2029 competence of National participation are in place. ticipation satisfactory. Reference Laboratory Keldur is designated Information distributed for Antimicrobial by MAR as the National to relevant domestic Resistance (NRL-AR) and Reference Laboratory for stakeholders. cooperation with the EU antimicrobial resistance Reference Laboratory for in animals in Iceland. Antimicrobial Resistance (EURL-AR). July 2024 National Action Plan (NAP) on Antimicrobial Resistance 49 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

5.1.6

5.1.6 Strengthen cooper- Inactive participation More active participation HRN MAR, URN, SVL, 3 2025 2029 ation with EU DG-SANTE in online meetings and in this forum. MAST, UST. (Health and Food Safety) events. Contact points 5. Increase participation in international cooperation - AMR One Health UST, MAST, and SVL. Networkand.

5.2

5.2 Strengthen cooperation 5.2.1 Maintain and SVL participates in WHO- Cooperation and SVL LSH, HRN. 1 2025 2029 with international organi- strengthen cooperation GLASS cooperation on participation increased. sations. with WHO on antibiotic the use of antibiotics Information distributed resistance and antibiotic and AMR. to relevant stakeholders. on actions against antibiotic resistance Output indicator: use. Measurement and assess-

5.2.2

5.2.2 Maintain and Cooperation is ongoing. A Cooperation and par- MAST Engir aðrir. 1 2025 2029 ment of Iceland's participa- strengthen cooperation representative from MAST ticipation satisfactory. tion in international coop- with WOAH. participates in WOAH Information distributed eration / The proportion of committees on antibiotic to relevant domestic projects and groups related use and resistance. stakeholders. to antibiotic resistance in which Iceland participates. Benchmark: Full participation in projects and groups related to antibiotic resistance by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 50 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

5.3

5.3 Strengthen Nordic 5.3.1 Ensure participation Participation in place Increased knowledge SVL MAST, UST, 1 2025 2029 cooperation. in expert and strategy by SVL, MAST, UST, SVEID- about antibiotic resis- SVEID-LSH 5. Increase participation in international cooperation groups of the Nordic LSH, and Keldur. tance and joint research og Keldur, HRN. Output indicator: Council of Ministers on projects in place. Measurement and assess- actions against antibiotic ment of Iceland's partic- resistance in the spirit of ipation in international One Health. cooperation/ The proportion

5.3.2

5.3.2 Strengthen joint Work has begun, Joint procurement HRN LSH 1 2025 2029 of projects and groups relat- procurement of anti- see: https://www. increased. on actions against antibiotic resistance ed to antibiotic resistance in biotics in the Nordic lyfjastofnun.is/frettir/ which Iceland participates. countries. norraenn-samvin- na-um-lyfjamal-styrkt-m Benchmark: ed-nyrri-stefnu/. Full participation in projects and groups related to antibiotic resistance by the year 2029. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 51 Responsible Priority of Current status Deliverables Other Start of End of Activities stakeholders activities Actions Objectives of activities of activities stakeholders activities (year) activities (year) of activities (1-3)

6.1

6.1 Ensure the implemen- 6.1.1 A multidisciplinary A multidisciplinary Active policy making HRN MAR, URN. 1 2025 2029 tation and execution of group of experts should group of experts is in interdisciplinary group 6. Ensure coordination and management of actions activities against antibiotic be appointed to oversee place, appointed for in place which reviews resistance in the near future. the implementation of two years. The group the government actions the activities against is currently tasked with against antibiotic Output indicator: antibiotic resistance and proposing actions and resistance. Multidisciplinary group to reassess individual individual projects. established. projects in the future. against antibiotic resistance in Iceland for the future Benchmark: Multidisciplinary group established for the future. July 2024 National Action Plan (NAP) on Antimicrobial Resistance 52 2. Cost estimate of the action plan

2.1 — Summary (ISK)

2.1 Summary (ISK) 2025 2026 2027 2028 2029 Alls Basic cost 109.481.938 106.481.938 103.681.938 103.381.938 119.781.938 542.809.690 Additional cost 292.855.562 276.855.562 224.855.562 233.355.562 214.980.562 1.242.902.810 Total cost 402.337.500 383.337.500 328.537.500 336.737.500 334.762.500 1.785.712.500 Based on price level 2025 Basic cost: Funding already being allocated Additional cost: extra funding needed July 2024 National Action Plan (NAP) on Antimicrobial Resistance 53

2.2 — Cost estimates of individual actions (ISK)

2.2 Cost estimates of individual actions (ISK) Responsible Total Actions Cost 2025 2026 2027 2028 2029 stakeholders 2025-2029 Basic cost 3.000.000 0 0 0 0 3.000.000 1. Promote targeted and HRN prudent use of antibiotics Additional cost 0 0 0 0 0 0 in humans and animals Basic cost 0 0 0 0 0 0 EL Additional cost 80.000.000 80.000.000 32.000.000 29.000.000 17.000.000 238.000.000 Basic cost 6.250.000 6.250.000 6.250.000 6.250.000 6.250.000 31.250.000 SVL Additional cost 3.593.750 3.593.750 3.593.750 3.593.750 3.593.750 17.968.750 Basic cost 11.000.000 11.000.000 11.000.000 11.000.000 11.000.000 55.000.000 LSH Additional cost 23.000.000 23.000.000 23.000.000 23.000.000 23.000.000 115.000.000 Basic cost 3.644.438 3.644.438 3.644.438 3.644.438 3.644.438 18.222.190 ÞÍH Additional cost 11.355.562 11.355.562 11.355.562 11.355.562 11.355.562 56.777.810 Basic cost 0 0 0 0 0 0 MAR Additional cost 0 0 0 0 0 0 Basic cost 6.700.000 6.700.000 6.700.000 6.700.000 6.700.000 33.500.000 MAST Additional cost 7.600.000 7.600.000 7.600.000 7.600.000 7.600.000 38.000.000 Basic cost 30.594.438 27.594.438 27.594.438 27.594.438 27.594.438 140.972.190 TOTAL Additional cost 125.549.312 125.549.312 77.549.312 74.549.312 62.549.312 465.746.560 Total 156.143.750 153.143.750 105.143.750 102.143.750 90.143.750 606.718.750 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 54 Responsible Total Actions Cost 2025 2026 2027 2028 2029 stakeholders 2025-2029 Basic cost 0 0 0 0 0 0 2. Limit the spread of antibiotic HRN resistance through information Additional cost 4.500.000 4.500.000 3.000.000 3.000.000 3.000.000 18.000.000 dissemination, education, and prevention Basic cost 8.593.750 8.593.750 8.593.750 8.593.750 8.593.750 42.968.750 SVL Additional cost 14.093.750 14.093.750 14.093.750 14.093.750 14.093.750 70.468.750 Basic cost 0 0 0 0 0 0 ÞÍH Additional cost 1.000.000 1.000.000 1.000.000 1.000.000 1.000.000 5.000.000 Basic cost 0 0 0 0 0 0 HH Additional cost 600.000 0 0 0 0 600.000 Basic cost 2.500.000 2.500.000 2.500.000 2.500.000 2.500.000 12.500.000 MAST Additional cost 6.400.000 4.900.000 14.400.000 13.400.000 7.900.000 47.000.000 Basic cost 11.093.750 11.093.750 11.093.750 11.093.750 11.093.750 55.468.750 TOTAL Additional cost 26.593.750 24.493.750 32.493.750 31.493.750 25.993.750 141.068.750 Total 37.687.500 35.587.500 43.587.500 42.587.500 37.087.500 196.537.500 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 55 Responsible Total Actions Cost 2025 2026 2027 2028 2029 stakeholders 2025-2029 Basic cost 3.000.000 0 0 0 0 3.000.000 3. Improve knowledge HRN of antibiotic resistance Additional cost 27.000.000 27.000.000 27.000.000 34.000.000 41.000.000 156.000.000 through monitoring and scientific research Basic cost 781.250 781.250 781.250 781.250 781.250 3.906.250 SVL Additional cost 7.500.000 7.500.000 7.500.000 7.500.000 7.500.000 37.500.000 Basic cost 0 0 0 0 0 0 LSH Additional cost 33.000.000 33.000.000 33.000.000 33.000.000 33.000.000 165.000.000 Basic cost 47.500.000 50.500.000 47.700.000 47.400.000 63.800.000 256.900.000 MAR Additional cost 16.000.000 21.000.000 16.000.000 21.500.000 16.000.000 90.500.000 Basic cost 6.700.000 6.700.000 6.700.000 6.700.000 6.700.000 33.500.000 MAST Additional cost 1.700.000 1.700.000 1.700.000 1.700.000 1.700.000 8.500.000 Basic cost 1.100.000 1.100.000 1.100.000 1.100.000 1.100.000 5.500.000 UST Additional cost 8.300.000 0 0 0 0 8.300.000 Basic cost 59.081.250 59.081.250 56.281.250 55.981.250 72.381.250 302.806.250 TOTAL Additional cost 93.500.000 90.200.000 85.200.000 97.700.000 99.200.000 465.800.000 Total 152.581.250 149.281.250 141.481.250 153.681.250 171.581.250 768.606.250 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 56 Responsible Total Actions Cost 2025 2026 2027 2028 2029 stakeholders 2025-2029 Basic cost 1.562.500 1.562.500 1.562.500 1.562.500 1.562.500 7.812.500 4. Contain the spread SVL of antibiotic resistance through Additional cost 2.375.000 2.375.000 2.375.000 2.375.000 0 9.500.000 intervention measures Basic cost 0 0 0 0 0 0 MAST Additional cost 1.700.000 1.700.000 1.700.000 1.700.000 1.700.000 8.500.000 Basic cost 0 0 0 0 0 0 URN Additional cost 7.000.000 7.000.000 0 0 0 14.000.000 Basic cost 0 0 0 0 0 0 UST Additional cost 10.600.000 0 0 0 0 10.600.000 Basic cost 1.562.500 1.562.500 1.562.500 1.562.500 1.562.500 7.812.500 TOTAL Additional cost 21.675.000 11.075.000 4.075.000 4.075.000 1.700.000 42.600.000 Total 23.237.500 12.637.500 5.637.500 5.637.500 3.262.500 50.412.500 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 57 Responsible Total Actions Cost 2025 2026 2027 2028 2029 stakeholders 2025-2029 Basic cost 0 0 0 0 0 0 5. Increase participation HRN in international cooperation Additional cost 2.000.000 2.000.000 2.000.000 2.000.000 2.000.000 10.000.000 on actions against antibiotic resistance Basic cost 6.250.000 6.250.000 6.250.000 6.250.000 6.250.000 31.250.000 SVL Additional cost 15.437.500 15.437.500 15.437.500 15.437.500 15.437.500 77.187.500 Basic cost 900.000 900.000 900.000 900.000 900.000 4.500.000 MAST Additional cost 1.700.000 1.700.000 1.700.000 1.700.000 1.700.000 8.500.000 Basic cost 0 0 0 0 0 0 MAR (Keldur) Additional cost 500.000 500.000 500.000 500.000 500.000 2.500.000 Basic cost 0 0 0 0 0 0 UST Additional cost 500.000 500.000 500.000 500.000 500.000 2.500.000 Basic cost 7.150.000 7.150.000 7.150.000 7.150.000 7.150.000 35.750.000 TOTAL Additional cost 20.137.000 20.137.000 20.137.000 20.137.000 20.137.000 100.687.500 Total 27.287.500 27.287.500 27.287.500 27.287.500 27.287.500 136.437.500 July 2024 National Action Plan (NAP) on Antimicrobial Resistance 58 Responsible Total Actions Cost 2025 2026 2027 2028 2029 stakeholders 2025-2029 Basic cost 0 0 0 0 0 0 6. Ensure coordination HRN and management of actions Additional cost 3.000.000 3.000.000 3.000.000 3.000.000 3.000.000 15.000.000 against antibiotic resistance in Iceland for the future Basic cost 0 0 0 0 0 0 MAR/MAST Additional cost 1.800.000 1.800.000 1.800.000 1.800.000 1.800.000 9.000.000 Basic cost 0 0 0 0 0 0 URN Additional cost 600.000 600.000 600.000 600.000 600.000 3.000.000 Basic cost 0 0 0 0 0 0 TOTAL Additional cost 5.400.000 5.400.000 5.400.000 5.400.000 5.400.000 27.000.000 Total 5.400.000 5.400.000 5.400.000 5.400.000 5.400.000 7.812.500 Total 402.337.500 383.337.500 328.537.500 336.737.500 334.762.500 1.785.712.500 Based on price level 2025 Basic cost: Funding already being allocated Additional cost: extra funding needed July 2024 National Action Plan (NAP) on Antimicrobial Resistance 59

2.3 — Cost estimates of stakeholders (ISK)

2.3 Responsible stakeholders Basic cost HRN Additional cost Basic cost EL Additional cost Basic cost SVL Additional cost Basic cost LSH Additional cost Basic cost HH Additional cost Basic cost ÞÍH Additional cost Basic cost MAR Additional cost Basic cost MAST Additional cost July 2024 National Responsible stakeholders Basic cost URN Additional cost Basic cost UST Additional cost Total Based on price level 2025 Basic cost: Funding already Additional cost: extra funding needed July 2024 National Action Cost estimates of stakeholders (ISK) Total Cost 2025 2026 2027 2028 2029 2025-2029 6.000.000 0 0 0 0 6.000.000 36.500.000 36.500.000 35.000.000 42.000.000 49.000.000 199.000.000 0 0 0 0 0 0 80.000.000 80.000.000 32.000.000 29.000.000 17.000.000 238.000.000 23.437.500 23.437.500 23.437.500 23.437.500 23.437.500 117.187.500 43.000.000 43.000.000 43.000.000 43.000.000 40.625.000 212.625.000 11.000.000 11.000.000 11.000.000 11.000.000 11.000.000 55.000.000 56.000.000 56.000.000 56.000.000 56.000.000 56.000.000 280.000.000 0 0 0 0 0 0 600.000 0 0 0 0 600.000 3.644.438 3.644.438 3.644.438 3.644.438 3.644.438 18.222.190 12.355.562 12.355.562 12.355.562 12.355.562 12.355.562 61.777.810 47.500.000 50.500.000 47.700.000 47.400.000 63.800.000 256.900.000 17.500.000 22.500.000 17.500.000 23.000.000 17.500.000 98.000.000 16.800.000 16.800.000 16.800.000 16.800.000 16.800.000 84.000.000 19.900.000 18.400.000 27.900.000 26.900.000 21.400.000 114.500.000 Action Plan (NAP) on Antimicrobial Resistance 60 Total Cost 2025 2026 2027 2028 2029 2025-2029 0 0 0 0 0 0 7.600.000 7.600.000 600.000 600.000 600.000 17.000.000 1.100.000 1.100.000 1.100.000 1.100.000 1.100.000 5.500.000 19.400.000 500.000 500.000 500.000 500.000 21.400.000 402.337.500 383.337.500 328.537.500 336.737.500 334.762.500 1.785.712.500 being allocated Plan (NAP) on Antimicrobial Resistance Government of Iceland Ministry of Health

National Action Plan (NAP) on Antimicrobial Resistance 2025-2029

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