National Action Plan on Prevention and Containment of Antimicrobial Resistance 2017–2022

NATIONAL ACTION PLAN ON PREVENTION AND CONTAINMENT OF ANTIMICROBIAL RESISTANCE REPUBLIC OF KENYA JUNE 2017 2017 -2022 National Action Plan for the Prevention and Containment of Antimicrobial Resistance, Nairobi, Kenya: Government of Kenya, June 2017. © 2017 Government of Kenya Enquiries and Feedback direct all correspondence to: Cabinet Secretary Ministry of Health P. O. Box 30016 GPO Nairobi 00100. Email: cabsecretary@health.go.ke Web site: www.health.go.ke June 2017 1 TABLE OF CONTENTS Foreword ............................................................................................................. 4 Preface ................................................................................................................. 6 Acknowledgement ............................................................................................... 7 INTRODUCTION ........................................................................................ 8 National Action Plan on Prevention and Containment of Antimicrobial Resistance 2017–2022 ........................................................... 9 OPERATIONAL FRAMEWORK ................................................................ 10 KENYAN GOVERNMENTS’ COMMITMENT TO IMPLEMENTING THE NATIONAL ACTION PLAN ............................... 11 National Government Coordination Mechanisms ............................................. 11 NASIC Steering Committee (NASIC-SC) .................................................... 12 NASIC Technical Committee (NASIC-TC) .................................................. 12 AMR Secretariat ......................................................................................... 13 County Government Coordination Mechanisms ............................................... 13 Partnerships and Implementation ...................................................................... 14 STRATEGIC OBJECTIVES ........................................................................ 15 Strategic Objective 1: Improve awareness & understanding of AMR through effective communication, education & training .................. 15 Strategic Objective 2: Strengthen the knowledge & evidence base through surveillance & research ................................................................. 19 Strategic Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and IPC measures .......................................... 24 Strategic Objective 4: Optimize the use of antimicrobials in human and animal health ...................................................................................... 30 Strategic Objective 5: Develop an economic case for sustainable investment that takes account of the needs of Kenya, and increase investment in new medicines, diagnostic tools, vaccines and other interventions ............. 36 MONITORING AND EVALUATION ......................................................... 40 LIST OF CONTRIBUTORS ....................................................................... 41 LIST OF COUNTY PARTICIPANTS .......................................................... 43 BIBLIOGRAPHY ........................................................................................ 48 X 2 National Action Plan on Prevention and Containment of Antimicrobial Resistance ACRONYMS AND ABBREVIATIONS AMR Antimicrobial Resistance AMU Antimicrobial Use ANALABS Analytical Laboratories APH Agriculture and Public Health APIs Active Pharmaceutical Ingredients ASAL Arid and Semi-Arid Land ASM American Society of Microbiology ASTs Antimicrobial Susceptibility Testing AU-IBAR African Union Inter-Africa Bureau of Animal resources CBO Community Based Organization CDC Centre for Disease Control and Prevention CME Continuous Medical Education COMESA Common Market for Eastern and Southern Africa CPD Continuous Professional Development ESBL Extended Spectrum B-Lactamase FAO Food and Agriculture Organization FBO Faith Based Organization GAP Global Action Plan GARP-K Global Antimicrobial Resistance Partnership-Kenya GDP Gross Domestic Product GFN Global Foodborne Infection Network GPPP Good Pharmaceutical Procurement Practices HCP Health Care Provider HCW Health Care Worker I CIPE International Centre for Insect Physiology ICT Information and Communication Technology ILRI International Livestock Research Institute IPC Infection Prevention and Control IPM Integrated Pest Management KAP Knowledge Attitudes and Practices KEBS Kenya Bureau of Standards KEML Kenya Essential Medicines List KEMRI Kenya Medical Research Institute X June 2017 3 KEPHIS Kenya Plant Health Inspectorate Services KICD Kenya Institute of Curriculum Development KFDA Kenya Food and Drug Authority KVB Kenya Veterinary Board MALF Ministry of Agriculture Livestock and Fisheries MAR Multiple Antibiotic Resistance MENR Ministry of Environment and Natural Resources MoH Ministry of Health MOEST Ministry of Education Science and Technology MRSA Methicillin Resistant Staphylococcus aureus NACOSTI National Council of Science and Technology NAP National Action Plan NASAC National Antimicrobial Stewardship Advisory Committee NASIC National Antimicrobial Stewardship Inter-agency Committee NEMA National Environmental Management Authority NGO Non-Governmental Organization NMRA National Medicines Regulatory Authority NMRL National Microbiology Reference Laboratory NPHLS National Public Health Laboratories NQCL National Quality Control Laboratories NTS Non- typhoidal Salmonella OIE World Organization for Animal Health POE Ports of Entry PPB Pharmacy and Poisons Board QA Quality Assurance QC Quality Control RDTs Rapid Diagnostic Tests SDA State Department of Agriculture SDL State Department of Livestock SOPs Standard Operating Procedure STGs Standard Treatment Guidelines TWG Technical Working Group UoN University of Nairobi WG Working Group WHO World Health Organization 4 National Action Plan on Prevention and Containment of Antimicrobial Resistance FOREWORD A ntimicrobial resistance (AMR) is a global threat that requires urgent collaborative action within and among countries. AMR occurs when a microorganism develops resistance to an antimicrobial drug to which it was previously sensitive. Bacteria, viruses, fungi and parasites that become resistant are able to withstand the effects of antimicrobials (e.g. antibiotics, antivirals, antimalarials, antifungals). This makes standard treatments ineffective and facilitates the spread of drug resistant infections, thus rendering the community vulnerable. The Global Action Plan (GAP) on AMR was adopted in 2015 by all countries through decisions in the World Health Assembly, the FAO Governing Conference and the World Assembly of OIE Delegates. This followed reports of alarming rates of resistance to hospital and community-acquired infections as well as reports of resistance in agriculture, livestock and fisheries. Countries agreed to have a national action plan on AMR that is consistent with the Global Action Plan, and to implement relevant policies and plans to prevent, control and monitor AMR. Having recognized the looming crisis, the Government has prioritized the prevention and containment of AMR, through a ‘One Health’ platform that embraces interdisciplinary collaborations and communications in all aspects of health care for humans, animals and the environment. The Ministry of Health and the Ministry of Agriculture, Livestock and Fisheries are leading the initiative, through the National Antimicrobial Stewardship Advisory Committee (NASAC), coordinating the efforts of the MOH, MALF, research, academia, civil society and other stakeholders. A country situation analysis concluded in March 2016, focusing on the human health, animal health, fisheries and agriculture sectors, indicated that Kenya is already experiencing high levels of antibiotic resistance. However, the rate or speed of increase of such resistance is unknown, because there has been no systematic AMR surveillance. In addition, some critical aspects of AMR control are inadequate, for example regulatory systems and structures, including the necessary enabling legislation. June 2017 5 The ongoing constitutional reforms in all sectors present a key opportunity for embedding AMR roles and responsibilities within existing institutions, or into the mandates of new institutions that are slated for creation or restructuring. Therefore, this National Action Plan (NAP) to Combat Antimicrobial Resistance in Kenya is informed by the situation analysis and the ongoing reforms, as well as the emerging evidence and lessons on AMR from other parts of the world. The NAP aims to provide a coherent policy framework and priority actions to contain the emergence and spread of AMR, through the following strategic objectives: • To improve awareness and understanding of antimicrobial resistance through effective communication, education and training • To strengthen the knowledge and evidence base through surveillance and research • To reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures • To optimize the use of antimicrobial medicines in human and animal health • To develop an economic case for sustainable investment that takes into account the needs of the country and investment into new medicines, diagnostics, tools, vaccines and other interventions. In order for Kenya to realize these objectives, everyone needs to act with utmost urgency to avert the AMR crisis. Without such integrated action, all the hard-won gains for health will be eroded, and diseases that were easy to treat will once again kill—a dire and present threat to this generation, and generations to come. Because the AMR threat is multidisciplinary, intersectoral and global, successful implementation of this Action Plan requires strong Government commitment and collaborative actions across the sectors and with our international partners. This Action Plan outlines the key AMR roles and responsibilities, and calls on everyone to act now, to avert the threat of AMR in Kenya and the world. Dr. Cleopa Mailu, EGH Cabinet Secretary Ministry of Health Mr. Willy Bett EGH Cabinet Secretary Ministry of Agriculture, Livestock Fisheries & Blue Economy Dr. Cleopa Mailu, EGH 6 National Action Plan on Prevention and Containment of Antimicrobial Resistance PREFACE A ntimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial drug to which it was previously sensitive. Bacteria, viruses, fungi and parasites that become resistant are able to withstand the effects of antimicrobials (e.g. antibiotics, antivirals, antimalarials, antifungals). This makes standard treatments ineffective and the community vulnerable as drug resistant infections can spread. The Ministry of Health and the Ministry of Agriculture, Livestock, Fisheries and Blue Economy are committed to exercising stewardship in the implementation of this National Action Plan (NAP) on prevention and containment of AMR. This is in line with the National policy on prevention and containment of AMR. The NAP is anchored on the following key strategic objectives: to improve awareness and understanding of antimicrobial resistance; to strengthen knowledge through surveillance and research; to reduce the incidence of infection; to optimize the use of antimicrobial agents; and to ensure sustainable investment in countering antimicrobial resistance. This is the first NAP on the Prevention and Containment of AMR in Kenya. It has been developed based on the National Policy on Prevention and Containment of AMR and the recommendations of the situation analysis on AMR conducted in 2011 and updated in 2016. This strategy provides a regulatory and implementation framework to establish and strengthen systems to contain the emergence and spread of AMR. Implementation of this strategy will require substantial funding and high-level political commitment. Because AMR is a multidisciplinary and intersectoral issue, successful implementation of this strategy will require effective coordination and collaboration among different sectors. June 2017 7 ACKNOWLEDGEMENT W e wish to acknowledge the Cabinet Secretaries for the Ministries responsible for Health and Agriculture for providing support and leadership in the development of this National Action Plan (NAP). We recognize the contribution of the Principal Secretaries for Health, State Department of Agriculture, Livestock, Fisheries and Blue Economy. We thank the Directors of Medical Services, Veterinary Services, Fisheries and Agriculture. We are grateful to the County governments for their invaluable input into this National Action Plan. We appreciate other Ministries, Departments and Agencies for their contribution in the process. The development of this National Action Plan was made possible through the FAO of the United Nations with support from the UK Department of Health under the Fleming Fund. We appreciate the contribution of the FAO team: Dr. Yilma Makonen, Dr. Bouna Diop, Dr. Tabitha Kimani, Prof. Fasina Folorunso, Dr. Stella Kiambi, Dr. Joseph Njuguna and Dr. Moses Gathura. We appreciate the input from the U.S. Centers for Disease Control and Prevention (CDC- Kenya and Atlanta) and the Center for Disease Dynamics Economics and Policy through Global Antibiotic Resistance Partnership with support. In addition, we thank the WHO for their input in this process. Finally, we appreciate the tireless efforts of the Technical Working Group comprising of Dr. Rachel Kamau, Dr. Eveline Wesangula, Mr. Stephen Cheruiyot, Dr. Jared Nyakiba, Ms. Susan Githii, Veronica Kamau, Felister Kiberenge, Dr. Allan Azegele, Dr. Jane Lwoyero and Dr. Christopher Wanga, Dr. Nathan Songok, Dr. Naphtali Mwanziki, Ms. Daisy Muriuki Ms. Teresia Karanja, Dr. Linus Ndegwa, and Prof. Samuel Kariuki. 8 National Action Plan on Prevention and Containment of Antimicrobial Resistance INTRODUCTION A ntimicrobial resistance threatens the very core of modern medicine and the sustainability of an effective, global public health response to the enduring threat from infectious diseases. Effective antimicrobial drugs are a pre-requisite for both preventive and curative measures, protecting patients from potentially fatal diseases and ensuring that complex procedures, such as surgery and chemotherapy, can be provided at low risk. Yet systematic misuse and overuse of these drugs in human medicine and food production have put every nation at risk. This action plan underscores the need for an effective “one health” approach involving coordination among numerous international sectors and actors, including human and veterinary medicine, agriculture, finance, environment, and well-informed consumers. The action plan recognizes and addresses both the variable resources counties have to combat antimicrobial resistance and the economic factors that discourage the development of new antimicrobials through research and development. Antimicrobial resistance affects all areas of health, involves many sectors and has an impact on the whole of society. Overuse and misuse/abuse of the antimicrobial agents in both human and veterinary practices have been documented to be responsible for the current crisis. In Kenya as the human population grows, increased use of antimicrobials to enhance food production may occur. This may result in commensurate increase in resistance to commonly-used antimicrobials, a scenario that does not bode well for treatment and management of infections in both humans and animals. Findings from studies and reports have shown a rising trend in AMR in key Gram positive and Gram negative bacterial pathogens including methicillin resistant Staphylococcus aureus (5–10%) from hospitalized patients, reduced susceptibility of community acquired pneumococci (19%), multi drug resistant extended spectrum beta lactamase producing Salmonella Typhimurium (65%) and Vibrio cholerae (68%) has been observed from outbreaks in Kenya. With increasing resistance to flouroquinolones also reported in typhoid outbreaks (25%), we have few antimicrobials options for treatment of these infections in resource limited settings. In view of the growing trends in AMR worldwide, the World Organization for Animal Health (OIE), the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) adopted the Global Action Plan to combat AMR (GAP-AMR) during the general assembly in May 2015. The GAP-AMR recommended a multi-sectoral approach from a One Health perspective, and sets out five strategic objectives: to improve awareness and understanding of AMR; to strengthen knowledge through surveillance and research; to reduce the incidence of infection; to optimize the use of antimicrobial agents; and to ensure sustainable investment in countering AMR. This National Action Plan (2017–2022) provides a common framework for action by all stakeholders in Kenya from different sectors, including human health, animal health, agriculture, fisheries and environmental sectors together with the civil society in managing and implementing appropriate AMR control activities, while being part of a collective strategy to meet the overall goal. June 2017 9 The goal of this National Action Plan is to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them. To achieve this it is important to: 1. Increase public knowledge and understanding of AMR and use of antimicrobials, particularly in those involved in healthcare, nursing care, food, and livestock production and aquaculture; 2. Understand the state of AMR emergence and prevalence, and use of antimicrobials (including surveillance and monitoring), and to assess the risk based on the understanding; 3. Enhance proper infection prevention and control (IPC); 4. Ensure antimicrobial stewardship (AMS) in order to reduce antimicrobial-resistant organisms; and 5. Accelerate research on the mechanism of AMR emergence and transmission, and its impact on social economy, and promote R&D for new preventive, diagnostic, and therapeutic technologies in order to ensure the continued availability of effective preventive, diagnostic, and therapeutic treatments for antimicrobial-resistant infections. Kenya has been tackling AMR issues since 2009 and this experience puts Kenya in the position to take leadership especially in African countries. The following priority measures over the next five years (2017–2022) were developed in this perspective. Relevant ministries, agencies, and organizations should engage in a common effort to undertake these measures under One Health approach. 10 National Action Plan on Prevention and Containment of Antimicrobial Resistance OPERATIONAL FRAMEWORK I n its aim of promoting countermeasures on antimicrobial resistance (AMR), this National Action Plan (NAP) is structured around Strategic objectives in the following five areas: (1) Public Awareness and Education, (2) Surveillance and Monitoring, (3) Infection Prevention and Control, (4) Appropriate Use of Antimicrobials, and (5) Research and Development, these are in line with the five strategic objectives set out by the Global Action Plan on AMR, The National Action Plan is organized around these objectives to facilitate collaborative action by the Kenyan Government, in partnership with development partners, individuals, and organizations aiming to strengthen healthcare, public health, veterinary medicine, agriculture, food safety, and research and manufacturing. Strategic interventions to achieve these objectives and specific actions to implement the strategies are presented for each objective as set out in Table 1. Table 1. Five Strategic Issues and Objectives for Countermeasures on AMR Strategic Issue Strategic Objective 1. Public Awareness and Education Improve public awareness and understanding, and promote education and training of professionals 2. Surveillance and Monitoring Continuously monitor antimicrobial resistance and use of antimicrobials, and appropriately understand the trends and spread of antimicrobial resistance 3. Infection Prevention and Control Prevent the spread of antimicrobial-resistant organisms by implementing appropriate infection prevention and control measures 4. Appropriate Use of Antimicrobials Promote appropriate use of antimicrobials in the fields of healthcare, livestock production, agriculture and aquaculture 5. Research and Development Promote research on antimicrobial resistance and foster research and development to secure the means to prevent, diagnose and treat the antimicrobial-resistant infections The strategies to achieve the above objectives are described in subsequent sections with their purposes, background, specific actions, related ministries, agencies, and institutions for the actions, and indices to evaluate the actions. June 2017 11 KENYAN GOVERNMENTS’ COMMITMENT TO IMPLEMENTING THE NATIONAL ACTION PLAN T he Kenyan government will lead and consolidate the efforts by individual programs or institutions through the development of policies, strategies and legal frameworks towards combating AMR. These efforts will encompass the different government departments and the private and non-governmental sectors. A commitment from all these stakeholders will allow for the simultaneously achievement of set targets and for more resources to be generated. The government will collaborate with the civil societies to raise awareness and disseminate information about AMR to the general public. NATIONAL GOVERNMENT COORDINATION MECHANISMS The Ministries responsible for Health and Livestock, Fisheries & Crops will jointly establish the multi sectoral AMR Secretariat hosted at the Ministry responsible for Health to coordinate the AMR agenda. Institutions that will play leading roles in the implementation of this Policy include National and County Ministries, Departments and Agencies responsible for Health, Agriculture (Crop, Livestock and Fisheries) and parastatals. The ministries responsible for health, livestock, crops and fisheries will implement this Policy and associated Strategic and Action Plans in a “One-Health” approach. The lead ministries will establish a National Antimicrobial Stewardship Interagency Committee (NASIC). NASIC will be governed through a Steering Committee (SC) and a Technical Committee (TC). 12 National Action Plan on Prevention and Containment of Antimicrobial Resistance NASIC Steering Committee (NASIC-SC) The NASIC-SC will comprise of Principal Secretaries of relevant ministries and two representatives of the Council of Governors. The NASIC-SC will be responsible for policy direction, resource mobilization, budget and work plan approvals. 1. Co-Chairs: Ministry of Health (MOH) and Ministry of Agriculture Livestock, Fisheries & Blue Economy (MALF) 2. Members: Ministry of Education Science and Technology (MOEST) Ministry of Environment and Natural Resources (MENR), the National Treasury & the Ministry of Industry, Trade and Cooperatives 3. The Committee may co-opt any department, bureau, office, agency, or instruments of the government, and request the county governments and private sector for assistance as the circumstances may require. Terms of Reference for the Steering Committee: • Policy direction • Approval of budgets • Approval of work plans • Resource mobilization NASIC Technical Committee (NASIC-TC) The NASIC-TC will comprise of Technical Directors of relevant ministries and experts. The NASIC-TC will be responsible for technical oversight, overseeing the implementation of the National Policy for AMR. It shall also ensure close coordination with other relevant stakeholders. Terms of Reference for the Technical Committee: • Formulate, monitor and evaluate implementation of the national action plan. • Collaborate and coordinate with government agencies, private and non-state actors. • Mobilize human and financial resources to support the plan through regular budget allocations and mainstreaming of activities within core programmatic areas. • Promulgate guidelines, make recommendations on rules and regulations, as well as possible penalties and sanctions for violations in accordance with existing laws, as may be necessary, related, or consistent with the purpose, intent, and objective of this National Action Plan. • Submit to the steering committee regular status reports, budgets, policy proposals on the implementation of the national action plan. • Establish thematic area advisory groups and technical working groups to facilitate effective implementation of the NAP. • Perform other functions and activities as may be assigned by the steering committee. The NASIC will meet quarterly. The responsible Principal Secretaries will select a chairperson on the basis of his or her expertise in leadership. Rotation of the chair among the Ministry of Health and the Ministry of Agriculture Livestock and Fisheries should be considered. NASIC will have a mechanism (with appropriate records) to ensure that its members have no conflicts of interests and that the work of the committee in the interests of public health is transparent. The NASIC shall review its composition annually to ensure representation of all relevant sectors and stakeholders. Table 2 indicates the actions to be taken by NASIC to support the operationalization of the NAP. June 2017 13 AMR Secretariat The NASIC will be supported by an appropriately resourced secretariat based at the MOH, responsible for the logistics of meetings; minute-taking; preparation and circulation of documents (e.g. background papers, reports and advisory notes to ministers); and storage and archiving. The head of the secretariat will be the national AMR focal point. Roles and Responsibilities of the AMR Secretariat: • Link the two levels of the NASIC at the National and County levels. • Coordinate policy implementation at the National and County Governments • Ensure continuous national, county and international stakeholder engagement • Representing the national AMR in meetings, conferences, stakeholder meetings and other relevant national and international forums. • Engage technical advisors and support the functions of TWGs. Composition of the Secretariat: The AMR Secretariat should be composed of members representing the relevant sectors, notably human health, animal health and production and the food and environment sectors. Representatives should be given sufficient authority by their institutions to make decisions. COUNTY GOVERNMENT COORDINATION MECHANISMS At the County Government, the lead Departments (Health and Agriculture) will establish a County Antimicrobial Stewardship Interagency Committee (CASIC). CASIC will comprise of County Executive Committee members, County Chief Officers of relevant Departments Technical County Directors and experts. The CASIC will be responsible for approving budgets and work plans, resource mobilization and implementation of the NAP at the county level. Terms of Reference for the CASIC: • Monitor and evaluate the implementation of the national action plan at the county level for the prevention and containment of AMR; • Mobilize human and financial resources to support the plan through regular budget allocations, mainstreaming of activities within core programmatic areas. • Enforce guidelines, rules and regulations in accordance with existing laws, as may be necessary, related, incidental, or consistent with the purpose, intent, and objective of this National Action Plan. • Submit to the CASIC regular status reports, budgets, policy proposals on the implementation of the national plan • Collaborate and coordinate with the county and national government and non-state actors NATIONAL AND COUNTY GOVERNMENT COORDINATION MECHANISMS The role of the Intergovernmental Relations. The Intergovernmental Relations Act, 2012 establishes several intergovernmental structures, which serve to facilitate greater intergovernmental cooperation and consultation under the devolved government model. The national government and county governments will use these structures to agree on implementation of the National Action Plan. 14 National Action Plan on Prevention and Containment of Antimicrobial Resistance Figure 1. Structure for Coordination Mechanism Na#onal An#microbial Stewardship Inter-­‐agency Commi;ee (NASIC) County An#microbial Stewardship Inter-­‐ agency Commi;ee (CASIC) County-­‐ Technical Working Groups Na#onal-­‐ Technical Working Groups Intergovernmental Rela#ons AMR Secretariat PARTNERSHIPS AND IMPLEMENTATION The implementation of this National Action Plan shall be guided by key institutional coordination and legal framework operating at different levels of the governance system in the country. This will require the sustained, coordinated, and complementary efforts of individuals and groups around the locally and globally, including public and private sector partners, healthcare providers, healthcare leaders, veterinarians, agriculture industry leaders, manufacturers, policymakers, and patients. Table 2. Strategic Interventions to Operationalize the National Action Plan Strategic Intervention Action Description Deliverables Timeframe Responsible Agencies Develop a National action plan and Monitoring and Evaluation Framework from a One Health approach Convene NASIC to launch the AMR National Action Plan Brief MOH/MALF and agencies on AMR Appoint NASIC members Generate report of launch 2017 MoH/MALF Develop an M&E framework for the AMR National Action Plan M&E Framework developed 2017 MoH/MALF Develop an AMR communication strategy Implement Communication Strategy 2017 MoH/MALF Mobilize resources and promote internal and external networking Submit project proposals to international organizations or relevant funding agencies Secure funding from government proposals submitted 2017–2022 MOH/MALF June 2017 15 STRATEGIC OBJECTIVES Strategic Objective 1: IMPROVE AWARENESS & UNDERSTANDING OF AMR THROUGH EFFECTIVE COMMUNICATION, EDUCATION & TRAINING Potential Measure of Outcome: extent of reduction in national human consumption of antibiotics and reduction in the volume of antibiotic use in food production. Human Health Sector AMR is a real public health crisis affecting the entire population that is exposed to antimicrobial resistant microorganisms (through human-human transmission, food or other transmission routes). Promotion of nation-wide measures against antimicrobial resistance (AMR) in human health and agriculture requires public awareness and understanding of AMR and antimicrobial use. The current level of public awareness is limited and AMR is not a core component of professional education, training or certification in both human and agricultural courses. Awareness campaigns are on-going through professional associations and stakeholder for a, in limited areas but these need to be scaled up countrywide. Therefore, there is need for increased awareness for the general public and professionals to ensure appropriate use of antimicrobials. However, it is important to develop AMR communication messages tailor made to suit different audiences and develop mechanisms to measure their effectiveness. There is need for creating awareness in relevant ministries to ensure concerted efforts in combating AMR. These efforts will also be replicated at county level. Combating AMR calls for commitment of national and county governments through resource mobilization and ensuring comprehensive sensitization at grassroots level. 16 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 1.1 Increase national AMR awareness through public communication programmes targeting the different audiences in human health & practice, including participation in an annual world antibiotic awareness campaign. 1.1.1. Undertake KAP on the effectiveness of existing IEC materials Gaps are inventoried 2017 MOH/MALF 1.1.2 Develop new and/or revise IEC materials IEC materials developed 2017–2018 MOH/MALF Professional Bodies Training Institutions 1.1.3 Develop a communication strategy for AMR AMR communication strategy developed 2017 MOH/MALF Professional Bodies Training Institutions Stakeholders 1.1.4. Conduct nationwide AMR awareness campaigns Nationwide AMR awareness campaigns conducted 2017–2022 MOH/MALF Professional Bodies Training Institutions Stakeholders 1.2 Establish AMR as a core component of professional education, training, certification & development for the health sectors 1.2.1. Perform an AMR needs assessment of healthcare professionals Needs Assessment conducted 2017 MOH/MALF Professional Bodies Training Institutions 1.2.2 Develop AMR curriculum for professional education and training AMR Curriculum developed 2017 MOH/MALF/ MOEST Professional Bodies Training Institutions 1.2.3 Mainstream AMR modules as a core component of professional education, training for certification AMR modules incorporated into professional education and training 2017–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions 1.3 Include antimicrobial use & resistance in school curricula to promote better understanding and awareness 1.3.1 Introduce AMR as a core component in the school health programmes within the ministry of Education and Health AMR introduced as a core component in school health programmes 2018–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions 1.3.2 Introduce AMR media programmes AMR media programmes launched 2018–2022 MOH/MALF/ MOEST KICD Professional Bodies Training Institutions June 2017 17 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 1.4 Capacity build media on AMR 1.4.1 Conduct media trainings on AMR Media trainings developed and conducted 2017–2022 MOH/MALF/ MOEST/MICT 1.4.2 Engage media to cover AMR events and occurrences AMR events covered by media 2017–2022 MOH/MALF/ MOEST/MICT 1.5 Prioritize AMR across key ministries through national risk registers 1.5.1 Establish an interagency committee of the key ministries and agencies Interagency committee established 2017 MOH/MALF Relevant Agencies 1.5.2 Develop risk registers with annual reporting Annual reports generated 2017–2022 MOH/MALF Relevant Agencies 1.5.3 Conduct annual inter ministerial AMR risk management workshops Annual risk management workshops conducted 2018–2022 MOH/MALF Relevant Agencies 1.6 Establish and support multi sectoral (One Health) platforms 1.6.1 Establish One Health platforms on AMR at national and county levels. One Health platforms established at national and county levels 2018–2022 MOH/MALF Relevant Agencies 1.6.3 Draw up inter-ministerial MOU for conducting operational procedures across the different sectors MOU for operational procedures developed 2017 MOH/MALF Relevant Agencies Animal Health and Crop Sector Antimicrobials for human and animal use can be accessed without prescription. With this regard, there is need to educate the farmers, animal keepers and the general public to enforce behavior change. Reducing the emergence and spread of antimicrobial resistance (AMR) requires antimicrobial stewardship (AMS) and infection prevention and control (IPC) among professionals. Behavior change based on increased knowledge and understanding of AMR is critical in addition to the strengthening regulations in this sector. Many farmers do not practice infection prevention measures in animals and crops and may resort to unnecessary use of antimicrobials; hence the need to emphasize adoption of good agricultural practices during sensitization campaigns. Agriculture input manufacturers should be sensitized to eliminate unnecessary use of antimicrobials during processing especially of animal feeds. 18 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 1.1 Promote Public Awareness, Knowledge and Understanding of AMR 1.1.1 Develop a communication strategy on AMR Communication strategy and implementation framework developed 2017 MALF 1.1.2 Undertake KAP on the effectiveness of existing IEC materials Gaps inventoried 2017 MALF Development partners 1.1.3 Develop AMU and AMR information tailor made to suit different target groups Adequate materials developed for the different target groups 2017 MOH/MALF/ MOEST Professional Bodies Training Institutions Stakeholders 1.1.4 Develop tools for communication and awareness on AMU and AMR Communication tools developed 2017–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions Stakeholders 1.1.5 Create awareness on AMU and AMR through varied communication methodologies Increase AMR communication fora 2017–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions Stakeholders 1.1.6 Disseminate AMU and AMR information to farmers, stakeholders, and general public (Indicator) Number of counties involved and persons reached calculated 2017–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions Stakeholders June 2017 19 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 1.2 Promote Education and Training on AMR of Professionals Involved in Related Fields 1.2.1 Facilitate capacity building for professionals engaged in AMR activities Professionals trained on AMR 2017–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions Stakeholders 1.2.2 Curriculum development for AMR training in universities, training institutions and schools AMR curricula developed and incorporated 2017–2022 MOH/MALF/ MOEST KICD Professional Bodies Training Institutions Stakeholders 1.2.3 Enhance multisectoral collaboration and allocate budgetary support towards “One Health Approach” at all levels of government Interagency rendered operational with financial support 2017–2022 MOH/MALF/ MOEST Professional Bodies Training Institutions Stakeholders Strategic Objective 2: STRENGTHEN THE KNOWLEDGE & EVIDENCE BASE THROUGH SURVEILLANCE & RESEARCH Potential Measure of Effectiveness: extent of reduction in the prevalence of antimicrobial resistance based on data collected through integrated programs for surveillance of antimicrobial resistance. Human Health Sector Establishing surveillance systems to detect and report resistant pathogens as well as the consumption of antimicrobials plays a critical role in developing evidence-based policies and guidelines to control/ limit overuse of antimicrobials which is a major driver of AMR. In Kenya surveillance and research on AMR is dependent on local research institutions, training institutions, health facilities and international research partners. More detailed surveillance has historically been limited to enteric pathogens which cause diarrheal diseases and significant mortality and morbidity in children. This data is insufficient to facilitate implementation of robust interventions. While the country cannot wait for all the data to initiate actions, data collection can be undertaken alongside risk mitigation. Building the capacity of health professionals and laboratories that take part in the process of surveillance enable reliable and robust diagnostic testing and proper data to be reported. With proper information and sharing of surveillance studies across borders, targeted approaches and treatment strategies may be developed to limit the spread and emergence of pathogens with AMR. 20 National Action Plan on Prevention and Containment of Antimicrobial Resistance Outcomes of this Objective: 1. Creation of a national public health network ( a National Network of antimicrobial resistance county laboratories) for resistance testing, a specimen repository for resistant bacterial strains, and a National Database of Resistant Pathogens 2. Routine reporting of antibiotic use and resistance data to National Coordinating Center by hospitals 3. Routine testing of zoonotic and animal pathogens for antibiotic susceptibility at regional veterinary investigation laboratories, using standardized testing methods and data sharing practices Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 2.1 Develop a National One-Health Surveillance system to Combat Resistance 2.1.1. Identify and establish a national reference center with the ability to systematically collect & analyze data National Reference Center Established 2017 MOH/MALF NPHLS NMRA 2.1.2 Create a national public health laboratory network. National public health lab network developed 2017 MOH/MALF NPHLS NMRA 2.1.3 Develop an integrated information management system for AMR Integrated information management system established 2018 MOH/MALF NPHLS NMRA 2.1.4 Develop AMR surveillance strategy Surveillance Strategy Published 2017 MOH/MALF NPHLS NMRA 2.1.5. Collect existing data on AMR status in Kenya Report of AMR status published 2017 MOH/MALF NPHLS NMRA KEMRI June 2017 21 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 2.2 Standardize Methods of Laboratory Testing and Strengthen Testing Functions of Antimicrobial Resistance at Public and Private Laboratories 2.2.1 Assess the AMR capacity in the existing NPHL, and other relevant public and private laboratories Report on AMR capacity in the existing laboratories published 2017 MOH/MALF NPHLS NMRA 2.2.2 Expand and strengthen the national and county infrastructure for public health surveillance Infrastructure for public health surveillance improved 2017–2022 MOH 2.2.2 Develop or review relevant SOPs for AMR tests Relevant SOPs for AMR tests in use 2017 MOH/MALF NPHLS NMRA 2.2.4 Conduct international and local training of technical personnel on monitoring, surveillance, testing methods and laboratory operations, including compliance to accreditation standards Technical personnel trained 2017–2022 MOH/MALF NPHLS NMRA Agencies 2.3 Implement Integrated One Health Surveillance Including Humans, Animals, Food, and the Environment 2.3.1 Launch the ‘One Health’ National Antimicrobial Stewardship Interagency Committee (NASIC) NASIC Launched 2017 MOH/MALF/ MENR NPHLS NMRA 2.3.2 Convene inter-sectoral coordination meetings Inter-sectoral coordination meetings held 2017–2022 MOH/MALF/ MENR 2.3.3 Participate in regional and international forums on AMR Reports of regional and international forums disseminated 2017–2022 MOH/MALF/ MENR 2.3.4 Develop an IT platform to enhance sharing/ communicating data on AMR to stakeholders AMR IT platform for information sharing established 2018 MOH/MALF/ MENR WHO/OIE/FAO 22 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 2.4 Promote Research 2.4.1 Identify AMR research agenda Research agenda identified 2018 MOH/MALF/ MENR 2.4.2 Promote the use of laboratory data for clinical decision making Laboratory data used for decision making 2018–2022 MOH/MALF/ MENR NMRA Research Institutions Agencies Animal Health and Crop Sector The extent and impact of AMR in the agricultural sector is not yet well defined. The judicious use of antimicrobials in food-producing animals is a critical step in lessening the AMR patterns seen in human medicine. This necessitates the establishment of an effective monitoring system to monitor trends in AMR from the point of slaughter to processing of animals, as well as the implementation of surveillance systems focusing on AMR mitigation strategies in animals. Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 2.1 Develop a national AMR surveillance system 2.1.1 Identify and define a national data repository and management centre National AMR data repository and management centre established 2017 MALF Development Partners 2.1.2 Develop an integrated information management system for AMU and AMR in food producing animals AMU and AMR integrated management system developed 2017 MALF Development Partners 2.1.3 Conduct data collection, sampling, testing, and analysis of antimicrobial drug residue in animals and the environment Data collected, samples tested and analysis done 2018–2022 MALF Development Partners 2.1.4 Develop a national surveillance plan based on WHO/FAO Codex Alimentarius for AMU and AMR data collection National surveillance plan developed 2017 MALF Development Partners 2.1.5 Collect and collate existing data on AMR status in Kenya from key stakeholders Results of current AMR data in the country documented 2017 MALF 2.1.6 Sensitize stakeholders on the status report (baseline) Baseline status of AMR disseminated 2017 MALF June 2017 23 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 2.2 Improve the capacities of health personnel, hospitals and laboratories 2.2.1 Identify MALF national and county laboratories for AMR surveillance and monitoring Laboratory designated for AMR 2018–2022 MALF 2.2.2 Develop, expand, and maintain capacity in national and county veterinary and food safety laboratories to conduct antibiotic susceptibility testing and characterize select zoonotic and animal pathogens. (Indicator) Number of laboratories developed with capacity to undertake AST 2018–2022 MALF 2.2.3 Conduct international and local training of technical personnel on monitoring, surveillance, testing methods and laboratory operations, including compliance to accreditation standards Competencies acquired 2018–2022 MALF Development Partners 2.3 Standardize Methods of Laboratory Testing of Antimicrobial Resistance 2.3.1 Assess the AMR capacity in the existing veterinary investigation laboratories (VILs), KEPHIS, PCPB and other relevant private laboratories Capacity gaps identified 2018–2022 MALF Development Partners 2.3.2 Develop or review relevant SOPs for standard tests (Indicator) Improved repeatability of test results 2017 MALF 2.3.3 Standardize the methods used in testing laboratories for livestock, farm-raised aquatic animals and pets. (Indicator) Increased uniformity in test results 2018–2022 MALF Partners 2.3.4 Provide training for internal quality control for tests Competence for quality control achieved 2019–2022 MALF Development Partners 2.3.5 Sample and test isolates for antibiotic susceptibility based on internationally accepted standards Test Method Validated 2018–2022 MALF Development Partners 24 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 2.4 Promote Research 2.4.1 Commission a baseline survey on uptake of the use of clinical laboratory examinations which enhance AMS Clinical practices that enhance antimicrobial stewardship established 2017–2022 MALF Research Institutions Agencies Development Partners 2.4.2 Identify AMR research agenda in Kenya Priority AMR Research Agenda in the country identified 2018 MALF Partners Strategic Objective 3: REDUCE THE INCIDENCE OF INFECTION THROUGH EFFECTIVE SANITATION, HYGIENE AND IPC MEASURES Potential Measure of Effectiveness: extent of reduction in the prevalence of preventable infections, and in particular the incidence of drug resistant infections in health care settings. Human Health Sector Better hygiene and infection prevention control are essential to limit the development and spread of antimicrobial-resistant infections and multidrug-resistant bacteria. To prevent transmission of AMR infections infection prevention and control, biosecurity, sanitation, hand washing, food and water safety and animal hygiene must be core components of infectious disease prevention. Vaccination, where appropriate as an infection prevention measure, should be encouraged. Prophylactic use of antibiotics in humans and animals, to prevent the acquisition and spread of diseases, and their use as a growth stimulant, promotes the development of AMR. Infection prevention and control including surveillance of health care associated infections (HAIs) should be institutionalized and strengthen. Kenya currently has IPC Policy, Strategy, Guidelines and Basic Training Course in place. This NAP supports the Implementation of the IPC Strategic Plan to reduce the incidence of infections and demand for antimicrobials and subsequently reduce AMR. June 2017 25 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 3.1 Implement the National IPC Strategy 3.1.1 Promote hand hygiene in healthcare facilities (Indicator) Improved adherence to hand hygiene 2017–2022 MOH Training Institutions Professional Bodies 3.1.2 Incorporate IPC as mandatory component in CPD offered by health regulatory bodies accredited and registered CPD providers IPC incorporated as a mandatory CPD component 2017–2022 MOH Training Institutions Professional Bodies 3.1.3 Incorporate IPC into in-service trainings for healthcare workers IPC incorporated into in-service training 2017–2022 MOH Training Institutions Professional Bodies 3.2 Develop & strengthen national policies and standards of practice on IPC 3.2.1 Develop and review SOPs and job aids on HAIs prevention based on the IPC guidelines SOPs and job aids for HAIs prevention in use 2017–2018 MOH Stakeholders 3.2.2 Develop an online training course on IPC and HAIs surveillance Online training launched 2017–2022 MOH Training Institutions Stakeholders 3.2.3 Train healthcare workers on IPC Healthcare workers skilled in IPC 2017–2022 MOH Training Institutions Stakeholders 3.2.4 Establish a national HAI surveillance system Reports on HAIs surveillance are generated 2018 MOH NHIF 3.2.5 Develop and/or review existing accreditation and quality assurance standards to ensure that they appropriately support compliance with reporting HAIs Accredited health facilities reporting on HAIs 2018 MOH NHIF 26 National Action Plan on Prevention and Containment of Antimicrobial Resistance Animal Health and Crop Sector Promote Infection Prevention and Control in Livestock Production, Aquaculture, Veterinary Medicine and Food Chain Improving the level of husbandry, hygiene management and maintaining the health condition of livestock are extremely important elements of controlling the occurrence and selection of antimicrobial resistant organisms leading to the prevention of the occurrence of infectious diseases in animals, to secure safety production of animal products, as well as to reduce instances of using veterinary antibiotics. They are also highly important from the viewpoint of reducing production costs. During food processing and distribution processes, promote countermeasures to reduce contamination with Antimicrobial Resistant Organisms and other microorganisms as well as to prevent food poisoning from occurring by promoting HACCP (Hazard Analysis and Critical Control Point). In all fields of livestock, farm-raised aquatic animals and pets, appropriate vaccination is important to prevent infectious diseases, in addition to thorough hygienic management. Reduce Environmental Contamination Studies have indicated that antibiotics can contaminate the environment through three principal channels: animal waste, human waste and manufacturing waste containing active pharmaceutical ingredients. This can result in soil, crops and water sources contamination and facilitate the development of antimicrobial resistance amongst the pathogens with which they interact creating environmental reservoirs of antimicrobial resistant bacteria. This calls for adequate treatment of waste products released into the local environment, limiting the sale and use of by products that could contain antimicrobials like manure from animals treated with antimicrobials. Public awareness on proper disposal of antimicrobials and treatment of hospital waste will be beneficial in reducing the burden of antimicrobial resistant pathogens in the waste water. June 2017 27 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 3.1 Implement & strengthen hygiene, & Food safety measures in food value chains and the environment 3.1.1 Promote and sensitize all actors along the food value chains on importance of infection prevention, control, hygiene, existing standards, guidelines and regulations Increased compliance to food safety measures and conformity to standards in food value chains 2017–2022 MALF Development Partners 3.1.2 Identify and develop interventions for the high risk food value chains where high AMU predispose to AMR Reduced AMU and exposure to AMR 2018–2022 MALF Development Partners 3.1.3 Develop and disseminate guidelines on effective agricultural , pharmaceutical industrial, hospital and human waste management Reduced AMR organisms in the environment Treated effluent from pharmaceutical industries 2018–2022 MALF MOH MENR Development Partners 3.2 Include hygiene & IPC as core (mandatory) components of training & education for veterinary professionals and in their CPD and accreditation/ registration 3.2.1 Incorporate hygiene, good agricultural, surgical, veterinary and aquaculture practices as mandatory components in CPD offered by KVB accredited and registered CPD providers Professional competence enhanced 2017–2022 MALF KVB 28 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 3.3 Strengthen animal health & agricultural practices through implementation of regulations and international standards such as OIE, Codex and IPPC. 3.3.1 Develop and roll out guidelines on good agricultural, hygienic, surgical, veterinary and aquaculture practices based on international standards and regulations. Behavioral change in agricultural, hygienic, surgical, veterinary and aquaculture practices. 2017–2022 MALF Development Partners 3.3.2 Develop training modules and train TOTs on good veterinary, agricultural, aquaculture, hygienic practices in the country Training modules developed. Increased pool of resource persons on AMR 2018–2022 MALF Development Partners 3.3.3 Train on good veterinary, agricultural, aquaculture, hygienic practices in various food value chains including risk based measures. Reduced risk of spread of AMR in agricultural, veterinary and aquaculture practices. 2018–2022 MALF Development Partners 3.4 Facilitate HACCP for food processing and the distribution process 3.4.1 Train public and private sector personnel on HACCP Adoption of HACCP by food processing industry 2018–2022 MALF Development Partners 3.4.2 Identify and promote use of rapid test kits for hygiene surveillance in food establishments. Reduced foodborne disease outbreaks and reduced AMU 2018–2022 MALF 3.4.3 Assess agricultural processes and establishments based on biosecurity and food safety standards for conformity Increased conformity of establishments to biosecurity and food safety standards 2017–2022 MALF 3.4.4 Assess agricultural processes and establishments on biosecurity and food safety measures for compliance Increased compliance of establishments to biosecurity and food safety regulation 2017–2022 MALF June 2017 29 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 3.5 Facilitate vaccination as a way of reducing animal infections 3.5.1 Sensitize county governments and farmers on the importance of vaccination in livestock, aquaculture and pets Reduction in AMU in animal health 2018–2022 MALF Development Partners 3.5.2 Sensitize on proper vaccine handling, use and storage Reduction in use of antimicrobials 2018–2022 MALF Development Partners 3.6 Facilitate animal identification and traceability 3.6.1 Enforce traceability along the value chain through animal identification and farm registration Targeted interventions implemented to reduce AMR and enhance food safety 2018–2022 DVS Development Partners 3.6.2 Sensitize farmers on animal identification and traceability Targeted interventions implemented to reduce AMR and enhance food safety 2018–2022 DVS Stakeholders Development partners 3.6.3 Review the existing legal framework relevant to animal identification and traceability Updated legal framework for animal identification and traceability 2018–2022 DVS 3.7 Facilitate crop identification and traceability 3.7.1 Provide training on plant identification and traceability to control plant diseases Improve plant health through plant identification and traceability 2018–2022 SDA Development Partners 3.8 Facilitate organic farming 3.8.1 Create awareness and sensitize farmers on the benefits of organic farming Reduction in use of antimicrobials in farming 2018–2022 MALF Development Partners 3.8.2 Assess and certify organic farms Increased numbers of farms conforming to organic farming requirements 2019–2022 MALF Development Partners 30 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Objective 4: OPTIMIzE THE USE OF ANTIMICROBIALS IN HUMAN AND ANIMAL HEALTH Potential measure of effectiveness: extent of reduction in National human consumption of antibiotics, the consumption of antibiotics used in food production and the use of medical and veterinary antimicrobial agents for applications other than human and animal health. Human Health Sector Prudent AMU is vital to sustainable prevention and treatment of microbial diseases. Areas of focus in this strategic objective include: development and implementation of guidelines, enhanced regulation, enhancing human resource capacity, ensuring access to essential antimicrobials as well as strengthening lab diagnostic capacity. Ensuring sustainable access to quality essential antimicrobials is therefore, integral in successfully hampering the development of AMR. Consumption of substandard or counterfeit antimicrobials containing less than the specified amount of the active ingredient, or consuming suboptimal dosage due to lack of supply or limited accessibility to antimicrobials contributes to the emergence of AMR. Strengthening the regulatory measures, tools and activities of the national drug regulatory agency in ensuring the safety, efficacy and quality of medicines from market authorization to post-marketing surveillance will help combat AMR. Efforts must also focus on sustaining an efficient supply chain system towards ensuring the availability or accessibility of quality medicines to all patients at all times with emphasis on appropriate use by both patients and prescribers. Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 4.1 Develop and review guidelines and strategies to optimize and regulate use of antimicrobials 4.1.1. Generate baseline data on AMU Report on antimicrobial use 2017–2018 MOH NMRA 4.1.2 Review the standard treatment guidelines for infectious diseases Standard treatment guidelines for infectious diseases reviewed 2017–2022 MOH NMTC NMRA 4.1.3 Develop a centralized surveillance system for antimicrobial consumption Reports for antimicrobial consumption generated 2017–2018 MOH NMRA 4.1.4 Develop guidelines and training modules for antimicrobial stewardship programs (ASP) in healthcare settings Guidelines and training modules on ASP in use 2017 MOH Stakeholders 4.1.5 Integrate ASP in accreditation systems and quality standards in health care facilities ASP included in accreditation system 2018 MOH NMRA NHIF June 2017 31 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 4.2 Implement ASP guidelines 4.2.1 Disseminate guidelines to the relevant healthcare staff ASP guidelines disseminated and implemented 2017–2022 MOH Stakeholders 4.2.2 Enforce compliance to guidelines in terms of purchasing, prescribing and dispensing of antimicrobials. (Indicator) Increased appropriate use of antimicrobials 2017–2022 MOH, NMRA Professional Associations Councils, Health Service Regulators, NHIF, Insurance Regulators, Financing Regulators-focused on what to reimburse 4.2.3 Monitor compliance to guidelines in terms of purchasing, prescribing and dispensing of antimicrobials Generate reports on compliance to guidelines 2017–2022 MOH, NMRA Professional Associations Councils, Health Service Regulators, NHIF, Insurance Regulators, Financing Regulators-focused on what to reimburse 4.2.4 Mandatory reporting of antimicrobial consumption and sales by health care facilities Increased compliance to reporting antimicrobial consumption 2017–2022 MOH NMRA 4.2.5 Establishment of Antimicrobial Stewardship Program (AMS) in hospitals Antimicrobial Stewardship Programs in Place 2018–2022 MOH County Governments 32 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 4.3 Improve the registration, marketing authorization and post-marketing surveillance of antimicrobials 4.3.1 Conduct joint monitoring missions to undertake efficient market and post market surveillance Access to quality antimicrobials assured 2017–2022 MOH NMRA 4.3.2 Enhance post marketing surveillance of antimicrobial products in healthcare Quality antimicrobials available 2017–2022 MOH/MALF NMRA 4.3.3 Streamline process of reviewing and releasing marketing authorization for new antibiotics that address priority infectious diseases in the country Efficient system of market authorization for new antibiotics 2017–2022 MOH/MALF NMRA 4.3.4 Ensure that distribution, prescribing and dispensing of antimicrobials is only carried out by licensed healthcare professionals and facilities. Only licensed health care professionals and facilities handling antimicrobials 2017–2022 MOH NMRA 4.3.5 Review healthcare laws and regulations related to AMU Healthcare laws and regulations reviewed to incorporate AMR 2017–2022 MOH NMRA 4.3.6 Conduct continuous monitoring of restricted and unregistered antimicrobials Register updated with restricted and unregistered antimicrobials 2017–2022 MOH NMRA 4.3.7 Identification of antimicrobials classified as critical for use in humans List of critical antimicrobials developed 2017 MOH/ MALF NMRA 4.3.8 Rationalization and harmonization of regulatory control over the manufacture and use of antibiotics in animals Harmonized regulatory control on manufacture and use of antimicrobials in animals 2017–2019 MOH/MALF NMRA June 2017 33 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 4.4 Foster an enabling environment for the rational use of medicines 4.4.1 Strict regulation of promotion and marketing of antimicrobials for human and veterinary us Regulated promotion and marketing of antimicrobials 2017–2022 MOH/MALF NMRA 4.5 Deployment of technical staff to support prudent use of antimicrobials 4.5.1 Assess human resources needs and develop a staffing plan Gaps in human resources identified 2017–2018 MOH 4.5.2 Recruit, train and deploy appropriate staff Appropriate Staff deployed 2017–2022 MOH 4.6 Ensure access to essential antimicrobial agents 4.6.1 Ensure continuous availability of essential antimicrobials in healthcare facilities across the country. Uninterrupted supply of essential antimicrobials 2017–2022 MOH KEMSA Stakeholders 4.6.2 Ensure a sustainable financial mechanism for essential antimicrobials. Accurate forecasting and budgetary allocation for essential antimicrobials 2017–2022 MOH KEMSA 4.7 Strengthen Quality Control capacity 4.7.1 Enhance laboratory capacity to monitor the quality of antimicrobial agents Quality antimicrobial agents available 2017–2022 MOH NMRA Animal Health and Crop Sector Antimicrobials are important in protecting the health and welfare of livestock and enhance the efficient production of safe food. On the other hand, their use always involves a risk of selecting antimicrobial resistant bacteria that might bring adverse effects to human medicine, veterinary medicine, and food safety. The local demand for animal food products such as milk, meat, fish and eggs, is bound to increase. This increased demand for animal protein engenders complex intensive production systems that results to an increase in the use of antimicrobial agents. The OIE, Codex Alimentarius Commission and other international organizations have formulated guidelines concerning the use of veterinary Antimicrobials. Appropriate use of veterinary antimicrobials will be ensured through various regulatory systems based on applicable laws. 34 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 4.1 Develop strategies to optimize and regulate use of antimicrobials 4.1.1. Undertake baseline study on AMU in animals, fish and plants in the country Antimicrobial consumption data established 2017–2022 MALF Stakeholders NMRA 4.1.2 Develop a database of registered antimicrobials, including quantitative production and importation Database of registered antimicrobials established 2017 MALF NMRA 4.1.3 Develop National AMU Guidelines in animals, fish and plants. Optimized AMU in livestock and crops 2017–2018 MALF Stakeholders NMRA Development Partners 4.1.4 Review National AMU guidelines Published guidelines reviewed 2018–2019 MALF NMRA Development Partners 4.2 Improve the registration, marketing authorization and post-marketing surveillance of antimicrobials 4.2.1 Develop SOPs for the process of review and release of marketing authorization for antimicrobials Register of approved Antimicrobials established 2017–2018 MOH/MALF NMRA 4.2.2 Undertake quality assurance of veterinary antimicrobial agents in the market Successful treatment of infectious diseases 2017–2022 MALF NMRA 4.2.3 Undertake active surveillance of unregistered antimicrobials in animals Unauthorized antimicrobials eliminated from the market 2017–2022 MALF NMRA June 2017 35 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 4.3 Develop tools to verify compliance to prudent use of antimicrobials 4.3.1 Develop SOPs for licensing of importers and exporters of antimicrobials. Register of authorized dealers established 2017–2022 MALF 4.3.2 Develop SOPs for licensing of antimicrobials manufacturers Register of approved manufacturers established. 2017–2022 MALF 4.3.3 Develop antimicrobial prescription registers Patterns of antimicrobial use established 2017–2022 MALF 4.4 Capacity building of staff to support prudent use of antimicrobials 4.4.1 Undertake assessment of human resource needs Human resource gaps identified 2018–2019 MALF PSC 4.4.2 Develop a training plan Competent staff deployed 2018–2019 MALF PSC Stakeholders 4.5 Ensure access to essential antimicrobial agents 4.5.1 Develop a platform of partnerships with healthcare professionals, organization, and consumer groups Essential antimicrobials available where and when required. 2019 MALF Stakeholders 4.5.2 Undertake review of regulations related to access to antimicrobials, especially in the distribution and sale. Controlled access to essential antimicrobials. 2019 MALF NMRA Legislature 36 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Objective 5: DEVELOP AN ECONOMIC CASE FOR SUSTAINABLE INVESTMENT THAT TAKES ACCOUNT OF THE NEEDS OF KENYA, AND INCREASE INVESTMENT IN NEW MEDICINES, DIAGNOSTIC TOOLS, VACCINES AND OTHER INTERVENTIONS Potential measure of effectiveness: extent of increase in sustainable investment in capacity to counter antimicrobial resistance for all countries, including investment in developing of new medicines and diagnostics. Human Health Sector Research is required on trends in resistance, practices and attitudes driving resistance in Kenya to inform appropriate interventions. In addition to investment in the discovery and development of new antimicrobials, diagnostic tools and vaccines, is required. Research and development of new antimicrobials though perceived as a less attractive business investment than that of medicines for chronic diseases, can provide opportunities for feeding the animicrobial pipeline. Research and investment in diagnostic tools and improved vaccines can contribute to the overall reduction in AMU. Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 5.1 Promote Research on Public Awareness/ Education on Antimicrobial Resistance, Infection Prevention and Control, and Antimicrobial Stewardship 5.1.1 Commission surveys on people’s knowledge, attitudes and practices to assess the impact of activities aimed at public awareness-raising and education Increased knowledge and awareness on AMR 2017–2022 MOH Stakeholders 5.2 Promote Research And Development for New Methods For Prevention, Diagnosis Treatment and Animal Vaccines and Promote the Cooperation Of Industry, Academia And Government 5.2.1 Create an enabling environment for public and private sector to undertake antimicrobial research and development of new antimicrobials and diagnostics. Increased collaboration between public and private sector on research 2017–2022 MOH NACOSTI Research Institutions KEVEVAPI 5.2.2 Advocate for the use of new rapid diagnostic tools (RDTs) for identification of causal organisms and AMR Improved management of infectious diseases 2017–2022 MOH Research Institutions Stakeholders 5.3 Develop plans to secure and apply the required financing 5.3.1 Prepare and submit medium term expenditure framework (MTEF) for the AMR program. AMR budgeted in the MTEF 2017–2022 MOH/MALF/ MENR NASIC management committee (NASIC-MC) June 2017 37 Animal Health and Crop Sector The causes, effects and impacts of AMR in the animal sector entail a better and deeper knowledge of the phenomena’s complexity. Veterinary antimicrobial consumption needs be further assessed in order to determine the correlation of AMR in both animal and human health in the country. Moreover, toxicological studies need to be performed to establish the safety of veterinary drug residues in the human diet, as well in the human intestinal flora. Researches are needed to enhance the development of effective strategies and alternatives to combat AMR in food-producing animals. Investment in the development of new antimicrobials, as well as in diagnostic tools and vaccines, is required. Research and development of new antimicrobialss though perceived as a less attractive business investment than that of medicines for chronic diseases, can provide opportunities for addressing the AMR challenge. Research and investment in diagnostic tools and improved vaccines can contribute to the overall reduction in AMU. To implement policies for combating antimicrobial resistance (AMR), it is important not only to accumulate existing scientific evidence and incorporate it into public health measures, but also to create new scientific evidence in Kenya and share it with society and the international community. Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 5.1 Promote Research on Public Awareness/ Education on Antimicrobial Resistance, Infection Prevention and Control, and Antimicrobial Stewardship 5.1.1 Commission surveys on people’s knowledge, attitudes and practices to assess the impact of activities aimed at public awareness-raising and education Gaps in KAP identified 2019–2022 MALF Partners 5.1.2 Commission research concerning changes in the resistance following the discontinuation of use of antibiotics for animals, and secondary risks Status of resistance pathogens established 2019–2022 MALF Partners 38 National Action Plan on Prevention and Containment of Antimicrobial Resistance Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 5.2 Promote Research And Development Of New Methods For Prevention, Diagnosis and Treatment and Promote The Cooperation Of Industry, Academia And Government 5.2.1 Promote the research and development of new vaccines to reduce incidence of infectious diseases in animals New vaccines developed 2019–2022 MALF Partners 5.2.2 Promote research and development on new preventive approaches that do not induce the emergence of antibiotic resistance organisms Guidelines and protocols on antimicrobial use developed 2019–2022 MALF Partners 5.2.3 Promote the use of rapid diagnostic tools for identification of causal organisms and AMR, which contribute to antimicrobial stewardship and AMR containment measures; Empirical treatment of AMR infections undertaken in animal health practice 2018–2022 MALF Partners 5.2.4 Promote use of simplified test methods that contribute to the prudent use of veterinary antibiotics at farm level. Prudent use of veterinary antibiotics occurring at farm level 2018–2022 MALF Partners 5.2.5 Review the procedure for registration of new medicine targeting antimicrobial resistant infections Reduction in treatment failures 2019–2022 MALF Partners June 2017 39 Strategic Intervention Activity Deliverables Timeframe Implementing Organization(s) 5.3 Develop plans to secure and apply the required financing 5.3.1 Prepare a medium term expenditure framework for the AMR program. Budget for the 5 year NAP developed 2017 MALF 5.3.2 Submit budget to NASIC steering committee for approval Annual budget approved 2017 MALF 5.3.3 NASIC-SC lobbies for inclusion of AMR program in National budget estimates with the relevant parliamentary committee AMR expenditure estimates captured in national budget 2017 MALF 5.3.4 Identify funding gaps for priority activities Priority activities and funding requirements established 2017–2022 MALF 5.3.5 Develop funding plans for each priority activity Proposals for priority activities developed 2017–2022 MALF 5.3.6 Submit funding plans to interested partners Sources of funding identified and proposals submitted 2017–2022 MALF Partners 40 National Action Plan on Prevention and Containment of Antimicrobial Resistance MONITORING AND EVALUATION U pon the official adoption of this National Action Plan, the AMR TWG shall develop a Monitoring & Evaluation Framework that includes targets and outlines the National Policy review process. A Monitoring and Evaluation framework for the AMR national action plan is critical in measuring the impact of proposed interventions. This Framework will be developed for each activity bearing a monitoring indicator to be measured in the process of its implementation. The framework will incorporate both objective and outcome indicators. Responsible Ministries/ Departments/Agencies will monitor and evaluate interventions identified in the NAP. A mid-term review will be done after two years to monitor the implementation of the NAP. End of term evaluation will be conducted in 2021. In addition, Annual Operational Plans, a Communication and Surveillance Strategy will be developed to support further implementation of the NAP. June 2017 41 LIST OF CONTRIBUTORS Dr. Allan Azegele MALF-State Department of Livestock Dr. Charles Kandie MOH-Division of Quality Assurance Dr. Chris Forshaw Senior Pharmaceutical Advisor-DANIDA Dr. Chris Wanga MALF-Policy and Planning Dr. Christabel Khaemba MOH-Pharmacy and Poisons Board Ms. Daisy Muriuki MALF-State Department of Fisheries Dr. Daniel Vanderende CDC-Atlanta Dr. David Silverstein The Nairobi Hospital Dr. Eveline Wesangula MOH-Patient Safety Unit Dr. Fasina Folorunsa FAO-Kenya Dr. Jane Lwoyero MALF-State Department of Livestock Dr. Jennifer Verani CDC-Kenya Dr. Jarred Nyakiba Pharmacy and Poisons Board Dr. Joseph Njuguna FAO-Kenya Dr. Lilian Musila USAMRU-Walter Reed Dr. Linus Ndegwa CDC-Kenya Dr. Lynda Oluoch Kenya Medical Association Dr. Margaret Oluka University of Nairobi, School of Pharmacy Dr. Mirfin Mpundu Ecumenical Pharmaceutical Network Dr. Moses Gichia FAO-Consultant Dr. Muthoni Kaminjuki Global Antibiotic Resistance Partnership Dr. Naphtali Mwanziki MALF-State Department of Livestock Dr. Nathan Songok MALF-Directorate of Veterinary Services-Medicines Dr. Rachel Kamau MOH-Patient Safety Unit Dr. Regina Mbindyo WHO-Kenya Dr. Stella Kiambi FAO-Kenya Dr. Tabitha Kimani FAO-Kenya Dr. Teresia Njuguna MALF-State Department of Agriculture Dr. Tom Menge Kenyatta National Hospital Dr. Ulzii Luvsansharav CDC-Atlanta Mr. Stephen Cheruiyot MOH-Policy and Planning 42 National Action Plan on Prevention and Containment of Antimicrobial Resistance LIST OF CONTRIBUTORS Mr. Stephen Manegene Ministry of Environment and Natural Resources Ms. Felister Kiberenge MOH-Patient Safety Ms. Susan Githii MOH-National Public Health Laboratries Ms. Veronica Kamau MOH-Patient Safety Prof. Fasina Folorunsa FAO-Kenya Prof. Lily Bebora University of Nairobi, College of Agriculture and Veterinary Services Prof. Samuel Kariuki Center for Microbiology and Research, KEMRI June 2017 43 LIST OF CONTRIBUTORS LIST OF COUNTY PARTICIPANTS 1 Francisca Onyango Agriculture Migori 2 Abel Nthuki MOH Kitui 3 Adon Mursal Health Isiolo 4 Alice Achieng Kafwa Vihiga Vihiga 5 Allan Azegele DVS Kabete 6 Amana D.Jilo Health Lamu 7 Andrew G. Thavyah UON/OHCEA Nairobi 8 Ann Nyaguthii Kimotho Fisheries Kirinyaga 9 Anne Kiruri Agriculture Nairobi 10 Annie Njeri Koimbori Crop Agriculture Kiambu 11 Anthony Kinyua Veterinary Tana River 12 Athman Mwatondo MOH-ZDU Nairobi 13 Aziz Kingi Agriculture Kilifi 14 Benard Omondi Ogutu Agriculture Mandera 15 Benson Siangot.M. Fisheries Kajiado 16 Carolyne Chemutai Sitienei Veterinary Nakuru 17 Charles Kandie MOH-DHSAQR Nairobi 18 Charles Kiprotich Kirui Fisheries Kericho 19 Charles Lekanayia Agriculture Kajiado 20 Charles Waweru Agriculture Kirinyaga 21 Charlotte Wanyonyi Agriculture Mombasa 22 Christina Mwachari University Of Maryland Nairobi 23 Cornel Omondi Fisheries Taita Taveta 24 Daisy Karimi SDF Nairobi 25 Daniel Kisee Veterinary Makueni 26 Daniel Ndungu Thuo County Govt Of Laikipia Nanyuki 27 David Bett Fisheries Kilifi 44 National Action Plan on Prevention and Containment of Antimicrobial Resistance 28 David Mululu Agriculture Tharaka Nithi 29 David Wanjala Agriculture Kwale 30 Dickson Ochieng Owai Baringo County Kabarnet 31 Dionisia Eruaki Agriculture Meru 32 Domiano Laikuru Agriculture Association Of Kenya Isiolo 33 Doris N. Kiia Agriculture Taita Taveta 34 Douglas Munge Veterinary County Government Nyeri 35 Dr. Ali Noor Mohamed Veterinary Mandera 36 Dr. Bernard Njau Veterinary Narok 37 Dr. David Nyagah MOH Tharaka Nithi 38 Dr. Evelyn Wesangula MOH Nairobi 39 Dr. George K. Singoei Veterinary Wajir 40 Dr. Idriss Yussuf MOH Garissa 41 Dr. John Chania Logedi Health Taita Taveta 42 Dr. Jonathan Munguti KMFRI Sagana 43 Dr. Joseph Githinji Livestock Isiolo 44 Dr. Joseph Yuaya Pharmaceutical Private Nairobi 45 Dr. Josephat Maluki Livestock Kitui 46 Dr. Joyce Mwaka Mwango Health Makueni 47 Dr. Julius Mutwiri Veterinary Taita Taveta 48 Dr. Kibachio Jozeph MOH Nairobi 49 Dr. Lily Kimuhu Health Kiambu 50 Dr. Maina Luzinga Health Kajiado 51 Dr. Malenga Cornel Veterinary Kilifi 52 Dr. Ndarua P.G Veterinary Kiambu 53 Dr. Nelly Rangara Health Kisumu 54 Dr. Peter Muhari Veterinary Nairobi 55 Dr. Rees Mbabu MALF/DVS Nairobi 56 Dr. Rhodamarion Gatutha Health Kirinyaga 57 Dr. Ruth Muthama Health Machakos 58 Dr. Suleiman Khanyare Health Wajir 59 Dr. Timaado Ngalo Health Marsabit 60 Dr. Wakhungu James Veterinary Kajiado 61 Dr. Wamalwa Kinyanjui IGAD Nairobi 62 Dr. Waweru David Munene Veterinary Machakos 63 Dr.Isaiah Owili Kiburo Veterinary Migori 64 Dr.Joseph Kiyeng Veterinary Elgeyo Marakwet 65 Dr.Lucy R. Kareithi Veterinary Tharaka Nithi 66 Dr.Maina Stephen Kungu Veterinary Muranga June 2017 45 67 Dr.Rachel Kamau MOH Nairobi 68 Dr.Thomas Manyibe Nyariki USAID, P&R Nairobi 69 Dr.Wameyo John Baringo County Government Kabarnet 70 Dr.Winnie Kanyi Health-Sanitation Muranga 71 Edwin Mwango Agriculture Nyeri 72 Edwin Robin Muga Fisheries Kisii 73 Eliud M. Kangethe Health-Sanitation Muranga 74 Elizabeth Wangari Mwangi County Govt Of Laikipia Nanyuki 75 Ephantus Kariuki Kavovwe Health Meru 76 Erastus Muriithi Agriculture Nairobi 77 Eric Chemiati Wandera Veterinary Kericho 78 Eric Mwenda Mbae Agriculture Meru 79 Esther Tallam Agriculture Elgeyo Marakwet 80 Fasina Folorunso ECTAD-FAO Nairobi 81 Felix K. Lagat Fisheries Bomet 82 Felix Muthomi Kithinji Livestock/Fisheries Isiolo 83 Fredrick Kangogo Fisheries Elgeyo Marakwet 84 Fredrick Kibocha Agriculture Nyeri 85 George Kamau Fisheries Nairobi 86 George Ondieki Veterinary Lamu 87 Grace Bore FAO Nairobi 88 Gunturu Revathi AKUH Nairobi 89 Gwiyo B. Haro Health Lamu 90 Hassan G.Omar Fisheries Wajir 91 Hassan M. Avar Agriculture Wajir 92 Idris Luhaga Veterinary Vihiga 93 Isaac Mwangi Agriculture Kirinyaga 94 Jackson Kinyua Livestock Garissa 95 Jael Maina Kibett Baringo County Kabarnet 96 James Gakuo Fisheries Nyeri 97 James Kihoro MOALF Kiambu 98 James Mbaria UON Nairobi 99 Jane Lwoyero MOALF Nairobi 100 Janet J.Mumba MOH Nairobi 101 Japhet Mumba Health Nairobi 102 Jeffrey Lejeune FAO-HQ Rome 103 Jennifer Kabora Agriculture Lamu 104 John Mbaluto MOALF Makueni 105 John N. Nyaga Agriculture Embu 106 John Njuguna FAO Nairobi 46 National Action Plan on Prevention and Containment of Antimicrobial Resistance 107 John Ohato Oronje Veterinary Busia 108 Johnkinyanjui AKUH Nairobi 109 Johnstone Nduma MOH Nairobi 110 Jonam Rasto Etyang Fisheries Kisumu 111 Jonathan Munyao Agriculture Makueni 112 Jonathan Mvwani KMFRI Sagana 113 Joseck David Mwaniki Ministry Of Agriculture, Irrigation& Fisheries Garissa 114 Josphat Maina Health Narok 115 Julius Kimitei MOH-ZDU Nairobi 116 Julius Likaria Agriculture Isiolo 117 Justin I. Nyaga Fisheries Embu 118 Kamau Kabiu Agriculture Muranga 119 Kamau Njenga MOA Mwingi 120 Kazungu Jonathan Ngowa Agriculture Kilifi 121 Kazungu Mwaro Agriculture Kwale 122 Kennedy Ateya Maseno Agriculture Kisii 123 Kivaria F.M FAO Kampala 124 Lillian Musila Kemri/Wrp Nairobi 125 Linus Ndegwa CDC Nbi 126 Margaret M.W Agriculture Machakos 127 Martha Mwathi MOH Nyandarua 128 Mary Karega Aburi Veterinary Kirinyaga 129 Mary Mwambia MOALF/SDL/DLP Nairobi 130 Mary R.Ndanyi DVS Kabete Vet Labs 131 Mercy Mwasaru MOH Embu 132 Mohamed Adaw Hassan Health Mandera 133 Mohamed Aden Fisheries Mandera 134 Moses Gichia FAO Nairobi 135 Musembi C.K. Kioko Veterinary Mombasa 136 Muthoni Kaminjuki GARP-K Nairobi 137 Mutuku Michael Silla Fisheries Kitui 138 Mwapitu Hamisi Mwalonya Veterinary Kwale 139 Napthali Mwanziki Livestock Nairobi 140 Nelson Kinyua Muraguri Agriculture Muranga 141 Njeru J. Mutegi Fisheries Trans-Nzoia 142 Nyaga Christopher Nkoroi Fisheries Machakos 143 Okinda Judith Auma Fisheries Migori June 2017 47 144 Okungu Suji Maurice Agriculture Narok 145 Olive Theuri Fisheries Kiambu 146 Patrick Mbaabu Fisheries Meru 147 Paul Muiumbi FAO-KE Nairobi 148 Paul Njonjo Livestock Kabete 149 Philip Iringo Veterinary Meru 150 Prof. Mitema Kikuvi UON Kabete Campus 151 Prof.James Mbaria UON Nairobi 152 Rachel Kamau MOH Nairobi 153 Rahab W. Maina M.O.H Nairobi 154 Ramadhan K. Mwamwero Agriculture Tana River 155 Ramona Ndanyi DVS Nairobi 156 Raphael Mwanyamawi Health Mombasa 157 Rinah Sitawa Wangila DVS-VEES Kabete Vetlabs 158 Robert Nyaroo MOALF Kajiado 159 Rose Kakai Maseno University Maseno 160 Samwel O. Oketch Health Migori 161 Serah Nderitu BHC Nairobi 162 Simon Losepicho Fisheries Mombasa 163 Simon Mung’ara Matara Fisheries Lamu 164 Stanley Nuguti Fisheries Makueni 165 Stephen Gichunge Fisheries Tharaka Nithi 166 Stephen Kiluva MOH Isiolo 167 Stephen Kyalo Musyimi Agriculture Garissa 168 Stephen Orot DVS Kabete 169 Susan Githii MOH Nairobi 170 Tabitha Kimani FAO Nairobi 171 Tafiqul Islam FAO-KE Nairobi 172 Teresia Karanja MALF-PAD Malf-Hqs 173 Thomas Mugo Fisheries Tana River 174 Tom Menge KNH Knh Nairobi 175 Vincent I. Kinyua Fisheries Narok 176 Vincent Ogwang Fisheries Nairobi 177 Violet Momanyi KALRO Kalro Kabete 178 Wamalwa Kinyanjui IGAD Nairobi 179 William Mugo Gathogo Agriculture Narok 180 Zelalem Tadesse FAO Daresalaam LIST OF COUNTY PARTICIPANTS 48 National Action Plan on Prevention and Containment of Antimicrobial Resistance BIBLIOGRAPHY 1. Global Antibiotic Resistance Partnership-Kenya Working Group (2011): Situational Analysis; Antibiotic Use and Resistance in Kenya (http://www.cddep.org/sites/default/files/garp/sitan/img/ screen shot 2015-12-15 at 12.06.41 pm.png) 2. Situation Analysis on Antibiotic Use and Resistance in Kenya (2016) 3. O’ Neill, 2014, Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations (https://amr-review.org/Publications) 4. World Health Organization 2015, Global Action Plan on Antimicrobial Resistance 5. World Health Organization 2015, Global Antimicrobial Resistance Surveillance System: Manual for Early Implementation. 6. World Health Organization 2015, Worldwide country situation analysis: response to antimicrobial resistance. (http://www.who.int/drugresistance/documents/situationanalysis/en/). June 2017 49 50 National Action Plan on Prevention and Containment of Antimicrobial Resistance