National Multi-sectoral Plan to Combat Antimicrobial Resistance for Tuvalu 2021-2025

Page 1 of 38 + National Multisectoral Plan to Combat Antimicrobial Resistance Tuvalu 2021 - 2025 Page 2 of 38 Foreword Page 3 of 38 Acknowledgements Thank you to the Ministry of Health and other relevant stakeholders from other Ministries who commented and gave invaluable assistance on the various drafts of the Tuvalu Multi-National Action Plan on Antimicrobial Resistance 2021-2025 and their support is gratefully acknowledged, Ministry of Ministry of Environment; Ministry of Education, Ministry of Transport & Customs; Ministry of Fisheries and trade; Ministry of Home Affairs and Rural Development, NGOs and Technical Partners. Thank you also to all participants from various unit/departments within the Ministry of Health who attended the AMR Consultation Workshops. Finally, thanks to WHO for technical support to formulate the Tuvalu Multi-sectoral National Action Plan on Antimicrobial Resistance 2021-2025. Page 4 of 38 Table of Contents PAGE FOREWORD 2 ACKNOWLEDGEMENT 3 TABLE OF CONTENTS 4 GLOSSARY 5 1.0 INTRODUCTION 6 2.0 COUNTRY CONTEXT 7 3.0 COLLABORATIVE APPROACH: DEVELOPMENT OF THE PLAN 9 4.0 SUMMARY SITUATION ANALYSIS ON AMR IN TUVALU 10 5.0 GOVERNANCE STRUCTURE 13 6.0 STRATEGIC OBJECTIVES 14 7.0 TUVALU NATIONAL AMR OPERATIONAL PLAN 2021-2025 15 8.0 IMPLEMENTATION FRAMEWORK 34 ANNEX 1 35 Page 5 of 38 Glossary AMC Antimicrobial Consumption AMR Antimicrobial Resistance AST Antibiotic susceptibility testing CSA Country situational analysis EQA External quality assessment IEC Information, Education, and Communication IPC Infection prevention and control M&E Monitoring & Evaluation MOE Ministry of Education MOH Ministry of Health MRSA Methicillin-Resistant Staphylococcus aureus M&E Monitoring and evaluation NGO Non-governmental organization NDTC National Drugs & Therapeutic Committee PMH Princess Margaret Hospital PPE Personal Protective Equipment SPC The Pacific Community TOR Terms of Reference TWG Technical Working Group WASH Water, Sanitation and Hygiene WHO World Health Organization Page 6 of 38 1.0 Introduction In 2014, the World Health Organisation (WHO) declared antimicrobial resistance as a global health threat1 that requires urgent collaborative action. High rates of resistance to hospital and community-acquired infections have been reported globally.2 While there is no specific data available on the AMR-situation in the country, health care workers confirm they see an increase in incidence of Methicillin-Resistant Staphylococcus aureus (MRSA) infections in Tuvalu, moreover in 2018 a single patient was identified with Drug resistant TB. In addition, health workers also suggest a number of driving factors for AMR are present in the country such as the misuse and overuse of antibiotics or poor infection prevention and control (IPC) in health care settings. Therefore, the Minister of Health of Tuvalu has now recognized antimicrobial resistance as a priority health agenda. It has endorsed the Action Agenda for Antimicrobial Resistance in the Western Pacific Region3, at the Sixty-fifth session of the Regional Committee for the Western Pacific Region in 2014 and subsequent re-committed at the World Health Assembly in 20154 and United Nations General Assembly in 2016. 5 This National Action Plan on Antimicrobial Resistance is aligned to the three priority actions listed in the Action Agenda for Antimicrobial Resistance in the Western Pacific Region In addition and the May 2015 the Global Action Plan on Antimicrobial Resistance, also endorsed at the Sixty-eighth session of the World Health Assembly. All Member States committed to developing national plans on antimicrobial resistance within the two years following endorsement. This plan is aligned to the five main principles of the global action plan 1) whole-of-society engagement, 2) prevention first, 3) access to effective treatment, 4) sustainability and 5) incremental country specific targets for implementation. 1 WHO (2014), WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health, Available at: https://www.who.int/mediacentre/news/releases/2014/amr-report/en/ 2 Ibid. 3 World Health Organization. Regional Office for the Western Pacific (2015), Action agenda for antimicrobial resistance in the Western Pacific Region, Available at: https://iris.wpro.who.int/handle/10665.1/10898 4 WHO (2015), Global Action Plan on Antimicrobial Resistance, Available at: https://www.who.int/antimicrobial-resistance/global-action-plan/en/ 5 UN General Assembly (2016), Political Declaration of the High-Level Meeting of the General Assembly on Antimicrobial Resistance, Available at: https://digitallibrary.un.org/record/845917?ln=en https://www.who.int/mediacentre/news/releases/2014/amr-report/en/ https://iris.wpro.who.int/handle/10665.1/10898 https://www.who.int/antimicrobial-resistance/global-action-plan/en/ https://digitallibrary.un.org/record/845917?ln=en Page 7 of 38 2.0 Country Context Tuvalu has a total land area of 26 square kilometres (km2) covering nine coral atolls and reef islands spread across more than 900,000 km2 of Pacific Ocean. Land resources are few and of poor quality and with the highest point of land only a few meters above sea level. About 60% of the population of approximately 11,000 resides on Funafuti where population density is high. Small size, isolation from markets, and a harsh physical environment are significant constraints to the country’s development. The low-lying atolls face occasional cyclones and the prospect of marine inundation in the event of rising sea levels. Higher sea levels already threaten the country's underground water table and the future habitation by the people of Tuvalu.6 Subsistence farming and fishing are the main economic activities. Fishing license fee earnings, revenues from Internet domain namely - TV, remittances from overseas workers, official transfers, and income from Tuvalu Trust Fund and the Falekaupule Trust Fund have provided the country with the main sources of income. A private sector-led economy has yet to emerge; and given the inherent constraints in such a small country, the private sector may never achieve lead status in the economy.7 Agriculture and fisheries remain important for food security, sustainable livelihoods and for national economic growth. Livestock production in the country is at subsistence level, with pigs and free-range chicken being the main livestock kept. Most households at the outer islands keep a few pigs and a number of local chickens. There is opportunity for some import substitution through improved livestock management and production. A decisive factor determining increased livestock production is the cost of animal feed since such feed has to be imported.8 Taiwan, Republic of Korea and the Government of Japan are major development partners. EU, DFAT, and NZAID are also considerable key development partners. Tuvalu has one hospital, the Princess Margaret Hospital (PMH), located on the main island of Funafuti. The PMH provides primary and secondary care services for patients from Funafuti and those referred from the eight outer rural islands. In the outer islands there are clinics manned by nurses who provide primary care and preventive services. Referral from the outer islands is both costly and time consuming for the local population. The furthest outer island is over 36 hours away by boat from the capital of Funafuti. 6 UNDP (2010), About Tuvalu, Available at: http://www.pacific.undp.org/content/pacific/en/home/countryinfo/tuvalu.html 7 FAO (n.d.), Situation Analysis and Agriculture Sector Overview Tuvalu, Available at: http://www.fao.org/fileadmin/user upload/sap/docs/Tuvalu.pdf 8 Ibid Page 8 of 38 Patients needing clinical care that cannot be offered at the PMH, are referred to bigger overseas hospitals through the Tuvalu Medical Treatment Scheme. Health services are all provided free of charge by the public sector as there is no private health sector. The 50-bed PMH offers basic routine medical, surgical, obstetrics and gynaecology (Ob&Gy) services. The general ward houses both medical and surgical cases aside from the Ob&Gy ward and the 4-bedded paediatric ward. There are no specialist physicians in Tuvalu so patients are seen by the local medical officers.9 Life expectancy at birth for Tuvaluans is 65 years for males and 69.5 years for females10 (based on 2018 estimates). The leading causes of morbidity and mortality remain non-communicable diseases, with the majority of deaths caused by cardiac diseases. Other common causes of mortality include diabetes mellitus, hypertension and cancers (all types). In 2017, acute respiratory infections dominated the outpatient morbidity data. 11 In addition, a brief look at key health indicators for Tuvalu suggests a high vaccines uptake and a low Under 5 maternal mortality rate. Key health indicators12 2013 2014 2015 2016 2017 Infant Mortality (number) Rate / 000 LB 12.0 (2) * 7.6 (1) 6.25 (3) 14.4 (4) 17.7 Perinatal Mortality1 (3) 12.6 Maternal Mortality (number) ratio / 00,000 LB 0 (1) 392 (1) 625 0 0 Crude Birth Rate 22.91 23.16 14.4 18.7 20.1 Teenage Births (%) 9.7 5 6.4 2.8 Measles Vaccine (MR 2) 84 91 76.5 93 93.2 Crude Death Rate 5.35 6.3 5.8 8.2 10.8 Under 5 yr. Mortality Rate 20.2 11 (1) 6.25 (1) 4.4 Contraceptive Prevalence Rate 26 31 36 36 33.4 Diabetes Prevalence % in > 15yr2 7.2 % 9 Ministry of Health of Tuvalu (2015), Health Reform Strategy 2016-2019. 10 CIA (2019), The World Factbook: Tuvalu. Available at: https://www.cia.gov/library/publications/the world-factbook/geos/tv.html. 11 Ministry of Health of Tuvalu (2015), Health Report 2017. 12 Ibid. Page 9 of 38 The health sector receives the second highest share (next to education) of the total government budget each year. In 2017, the Ministry of health budget made up 13.4% of the total government budget, whilst the Ministry of Education received 18%. Public expenditure on health has been increasing over the past four years. Compared to other Pacific Island countries, Tuvalu has one of the highest health expenditures as percentage of GDP and per capita spending on health. Accounting for around 30 % of annual expenditure, overseas referral and treatment of cases continues to be major challenges for the health service as high curative health services do compromise funding to preventive health programmes.13 Furthermore, overseas diagnostic and laboratory costs are also increasing. It is anticipated that with improved staffing in the outer islands, referral of patients will progressively decrease. Separately, improved local clinical care is expected to reduce the need for overseas medical referrals. 3.0 Collaborative Approach - Developing the Plan A stakeholders’ consultation workshop was conducted from 13 to 14 March 2019 with WHO technical support. The Ministry of Health Tuvalu took lead in these multi-sectoral workshops and updated forum on tripartite AMR country situation analysis (CSA) with presentations from key partners. Findings were discussed and country-specific recommendations and interventions were identified as next steps towards the development of this Plan. Published and unpublished data reviews and surveys with prescribed focus areas was undertaken. Plan was endorsed by the Honourable and notified at the WHO Regional Country Meeting (RCM) about a month later, see figure 1. Figure 1 – Diagram of Collaborative Approach 13 Ibid. Page 10 of 38 4.0 Summary of brief Situational Analysis on AMR in Tuvalu Synthesising information, aligned to the 5 GAP strategic objectives; simplified to 8 focus areas, helped visualise current status of AMR in Tuvalu, Figure 2 and narrative format. NDTC secretariat can update and use the radar chart as a tool to monitor progress with a target to reach at least 80% in 5 of 8 focus areas over the NAP lifetime, priority on surveillance capacity and systems. Figure 2 – Radar Chart for Situation Analysis on AMR Focus Area 1 – Leadership, Governance, Legal Framework, Human Resources and National Action Plan on AMR. At 80% overall grading. With completed NAP, the MoH will continue to strengthen the tripartite partnership on the One Health Approach for AMR. Like other PICs, country response to AMR is currently Human Health-centric. Medicines and antimicrobials are governed by the Tuvalu Pharmacy and Therapeutic Products Act (2016) and as well as the National Medicine Policy; mandates the National Drugs & Therapeutics Committee (NDTC) to oversee the selection and monitor the rational use of Essential Medicines (EMS). NDTC is mandated under the NMP to take on other functions such as management of NAP. MoH is committed to updating the 2008 Essential Medicines List (EML) edition. The Pharmacy Department procures medicines on the EML including antimicrobials. EMS are procured from pre-qualified suppliers based on consumption data only, as limited capacity to use epidemiological data. All EMS and medical services are free of charge. A sole pharmacy at PMH and eight outer islands clinics; antibiotics or other prescription medicines can only be dispensed at the hospital pharmacy; it is understood this policy is complied with. Provisions in the Act allow licensed small retail shops to sell OTC medicines only.14 However, regular monitoring is required. HR: In other sectors and HRH remains a challenge, one officer or a team is tasked with multiple responsibilities; sustainability is a real challenge. No trained veterinarian in country. Shortage is exacerbated by an overseas training scheme allowing qualified personnel to undertake a leave of absence to study or work abroad; many opt to work and reside abroad. 14 Ministry of Health of Tuvalu (2016), Pharmacy and Therapeutic Product Act (act. 6/2016), Available at: https://tuvalu-legislation.tv/cms/images/LEGISLATION/PRINCIPAL/2016/2016 0006/PharmacyandTherapeuticProductsAct2016 1.pdf Page 11 of 38 Focus Area 2 - Awareness Campaigns: Members of Public & training for professionals: At 10% grading, given NAP absence, limited awareness to public and training of professionals on AMR. Since 2016, hype of activities observed in November for World Antibiotic Awareness Week (WAAW) with no regular continuity. High level engagement from senior MoH and hospital staff. IEC materials were developed in the local language and displayed in several wards and pharmacy at PMH. MoH commits to conducting community awareness in villages and islands. Focus Area 3 - National AMR Surveillance: Capacity & Systems: At 0% and is the Priority focus area for Tuvalu. AMR intelligence is the key catalyst in planning and decision making in all sectors. HH: One laboratory at PMH, Funafuti Island, a solo laboratory technician provides haematology, serology, chemistry, immunology services except full-scale microbiology. Key microbiology equipment urgently requires maintenance. No qualified microbiologist; since 2016/2017, the microbiology section is no longer routinely conducting antibiotic sensitivity testing (AST). Quality control testing is not being performed on a regular basis, lack of control organisms. The laboratory has not participated in an EQA scheme. With Global Fund and UNDP support, a GeneXpert machine was acquired in 2017, for TB related tests only. An estimated 10 samples are tested on a weekly basis. AH: The department of fisheries has a laboratory, but its capacity to test for antimicrobial residues is unclear. Construction of a laboratory for the animal health sector is currently discussed; hence neither testing of antibiotic residue in animals nor animal products is conducted. Focus Area 4 – Rational use of antimicrobials: Public health sector: At 10% grading, the Antibiotic (AB) Standard Treatment Guidelines 2010 is in use,15 NDTC is committed to develop a more detailed national antibiotic guideline. AB is a prescription only EM in Tuvalu.16 No official data is available, key Informants stated high compliance to good prescribing habits. However, exceptions observed with the eight outer island clinics that provide services to about 4000 persons. There are no doctors at these clinics, nurses provide services and ABs are often dispensed without prescriptions. The PMH pharmacy department provides a medicines cart (includes commonly used ABs) to the on-call physician to allow access to medicines 24h/7d. The on-call physician can dispense ABs without a prescription and many times, information system (IS) entries on AB are not done. Msupply™ is the Pharmacy IS that tracks inventory. A summary report showed Amoxicillin oral formulations as widely used. 3rd generation cephalosporins (ceftriaxone injection) is available as last line treatment. A baseline behavioural survey is planned in the NAP; CSA workshop participants highlighted the following drivers of AMR: 15 Ibid. 16 Ministry of Health of Tuvalu (2010), Tuvalu Standard Treatment Guidelines (2010), Available at: https://www.who.int/selection medicines/country lists/TuvaluSTG 2010.pdf?ua=1 ×Limited knowledge - ABs commonly shared between friends & families ×Patients demand doctors to prescribe ABs × ABs irrationally prescribed to treat bacterial infections ×ABs irrationally prescribed for flu + for common cold ×Doctors pressured by families to prescribe Antibiotics ×Irresponsible Antibiotics dispensed by HH care worker to families & friends ×ABs are free of charge – notion of right to demand for ABs. Page 12 of 38 Focus Area 5 – Immunisation, IPC, WASH and AMR stewardship programme: At 80% grading. Immunisation: EPI coverage ranges from ≥95% for measles and DPT;17low risk of vaccine preventable diseases outbreaks. In 2019, ADB project supported rotavirus, pneumococcal conjugate and human papillomavirus vaccines introduction and cold chain infrastructure strengthening. With high vaccines uptake, Tuvalu foresees >80% Covid19 coverage for eligible persons at the end of 2021. IPC: SPC technical assistance, to endorse final new comprehensive national IPC policy and updated guidelines. CSA highlighted, IPC Policy & Guidelines implementation limited by funding and HRH constrains. IPC Committee tasks: WASH: > 91% of population have access to improved water and sanitation. Water supply is primarily dependent on rainwater catchment with above and below ground storage. Water quality testing is limited to hydrogen sulphide (H2S) kits, for E. coli detection. In 2013, DFAT provided large 10kL rain water tanks to every family, better water access. Awareness campaigns, good hygiene practices (such as boiling water, hand washing) has improved. Sanitation via outdoor toilets connected to septic tanks. Historically, outbreaks of diarrhoeal illness, typhoid and Hepatitis A have occurred. While there is no official data, smaller scale outbreaks of food borne diseases occur, particularly on outer islands due to poor water, poor sanitation and storage conditions of food. A Food Safety Act is in place, no dedicated food safety department to implement and monitor the Food Safety Act. AMR Stewardship: Limited capacities and to strengthen during NAP lifetime, linked to focus area 4. Focus Area 6 - Research and Innovation: At 0% grading, no AMR intelligence, limited research conducted on AMR. Strengthen capacities by twinning with regional academia and other PICs. Focus Area 7 – One-Health Engagement: At 0%, remains Human Health-centric and improve during NAP lifetime. No AB awareness conducted by Department of Agriculture (DoA). Animal Health: Land: Subsistence agriculture is a way of life, limited to chicken and pig husbandry. Reports of sporadic AB use in pigs. No systematic AB import and use in pigs. DoA neither maintains a formal AB registry nor record. No system to monitor the use of ABs in animal or farming practices. Sea: Tuvalu is surrounded by the sea, fishing is widespread and for domestic consumption only, commercialisation unsuccessful. Currently no antibiotics are routinely being used for aquaculture or in fish feed. EH: High Climate Change impact, fragile island state. Focus Area 8 – Sustainability: At 80%, continued development partners’ support pledged. Investment case to cost and assign annual budget for NAP is dependent on sound AMR intelligence by strengthening HR capacities, AMR stewardship and surveillance systems. 17 WPR-2018-DHS-025-tuv-eng.pdf (who.int) ❖ PMH formed IPC Committee. Finalise IPC policy, guidelines & a prioritised OPR work-plan. ❖ DFAT to bring in a temporary IPC officer to lead & mentor IPC policy/guidelines in PMH ❖ PMH IPC set up sub-optimal in wards and a small isolation ward. ❖ Variable IPC practices by hospital staff. ❖ Water is readily available. ❖ PPE and soap shortages occurs from time to time. During CSA visitation, gloves were not readily available for health workers in front line clinical areas. In 2018, MoH conducted a health security review, risks in importing AMR pathogens. The Tuvalu Medical Treatment Scheme sends patients with complex medical conditions to Fiji, India and Malaysia for tertiary care, includes surgical & other invasive procedures with increasing hospital-stay (up to 6 months or more in India, and long term stay for renal dialysis in Suva pending final decisions to establish a chronic kidney disease program and haemodialysis in PMH). Risks can be managed, MoAs with these providers to be renegotiated, including screening and certification of AMR-free status on discharge and prior to home travel. Routine screening for AMR pathogens by the PMH laboratory if patients are readmitted upon return. Topic of Interest from 2018 https://iris.wpro.who.int/bitstream/handle/10665.1/14064/WPR-2018-DHS-025-tuv-eng.pdf Page 13 of 38 5.0 Governance of Antimicrobial Resistance in Tuvalu One Health Approach is key to successfully containing AMR in Tuvalu. The cabinet is chaired by the Honourable Prime Minister and a direct line of reporting from the Government Advisory Committee (GAC) highlights the high-level political commitment to tackle AMR. Cabinet will provide high-level strategic and political support to the country’s response to control and contain AMR. The AMR focal point in Cabinet for is the Honourable Minister of Health, who will act as the bridge between Cabinet and GAC. The National Drug and Therapeutics Committee (NDTC) is the operational arm to implement AMR activities and will reports directly to GAC. Cabinet, GAC and NDTC will incorporate AMR as one of their priority functional agenda. The governance structure is aligned to the established, functional framework and coordinated mechanism to oversee implementation, monitoring and reporting of the National Action Plan on AMR in Tuvalu from Q4, 2021 – 2025. Figure 2. Refer to Annex 1 for more details. Figure 2 – Schematic of Governance Structure of Antimicrobial Resistance in Tuvalu Page 14 of 38 6.0 Strategic Objectives of AMR in Tuvalu Page 15 of 38 7.0 Tuvalu National AMR Operational plan (Years: 2021 - 2025) 1. Multi stakeholder mechanisms to combat AMR established and operational Goals Year 1 Year 2 - 3 Year 4 Activity Responsible Agency Activity Responsible Agency Activity Responsible Agency 1.1 Establishment of AMR governance structure for implementing the national action plan 1.1.1 AMR sub committee structure established and operational under the NDTC > Identify reporting structure and communication channel for the AMR Sub committee in Tuvalu under the NDTC Ministry of Health > NDTC/AMR Sub-committee meetings on quarterly basis NDTC/AMR Sub committee > Annual report on the work of AMR committee NDTC/AMR Sub-committee > Develop and finalize terms of reference for the AMR sub committee > Review/evaluate in year three ToRs of committee 1.1.2 National action plan regularly monitored > Hold a quarterly meeting to discuss implementation of the national action plan NDTC/AMR Sub committee > Hold a quarterly meeting to discuss implementation of the national action plan NDTC/AMR Sub committee > Hold a quarterly meeting to discuss implementation of the national action plan NDTC/AMR Sub-committee Page 16 of 38 > Annual meeting for M&E of AMR action plan implementation and making amendments to the plan > Annual meeting for M&E of AMR action plan implementation and making amendments to the plan > Review/endorsement of amended AMR national action plan 1.2 Enforcement of appropriate legislations in all sectors 1.2.1 Strengthened legislation of AMR in both human and animal sector > Review of existing legislation and ensure it incorporate clauses related to the use of antimicrobials in both human and animal health Relevant Ministries in collaboration with NDTC AMR Sub committee > Develop new legislation on AMR, where applicable Relevant ministries > Develop new legislation on AMR, where applicable (continued) Relevant ministries 1.3 Ensure sustainable resources to implement the National Action Plan 1.3.1 A dedicated budget for the governance > Consultation with key stakeholders for costing the AMR activities Ministry of Health, NDTC/AMR Sub committee > Formal submission of costed plan to the cabinet for endorsement NDTC/AMR Sub committee > Conduct consultation meeting with key partners for the identification of funding sources NDTC/AMR Sub-committee Page 17 of 38 of the National Action Plan secured (budget for meetings, reports.) outlined in the National Action Plan > A dedicated fully funded staff appointed to run AMR secretariat and AMR champions/focal points in different sectors identified 1.3.2 A dedicated budget for AMR-specific activities (awareness, surveillance, monitoring) secured > Consultation with key stakeholders for costing the AMR activities outlined in the National Action Plan > Identify and assess hospital and 8 health facilities in outer islands to ensure human and financial capacity to prevent, control and respond to AMR NDTC/AMR Sub committee > Conduct consultation meeting with key partners for the identification of funding sources > Formal submission of costed plan to the cabinet for endorsement Page 18 of 38 2. Improving awareness of AMR and foster behavioural change across all institutions, sectors and communities Goals Year 1 Year 2 - 3 Year 4 - 5 Activity Responsible Agency Activity Responsible Agency Activity Responsible Agency 2.1 Promote awareness raising, information sharing on AMR and rational use of antimicrobials across institutions, sectors and community 2.1.1 Awareness on AMR raised in different sectors > Develop IEC materials on AMR for the general public and policy makers NDTC/AMR Sub committee & relevant ministries > Develop IEC materials on AMR for farmers, agricultural sector NDTC/AMR Sub committee & relevant ministries > Conduct regular AMR advocacy and awareness by using various means of communication in particular radio or social media NDTC/AMR Sub committee & relevant ministries > Hold annual awareness campaign to celebrate World Antibiotic Awareness Week Island leaders, NGO’s, Civil societies, churches > Conduct regular AMR advocacy and awareness by using various means of communication in particular radio or social media Island leaders, NGO’s, Civil societies, churches > Engage Island leaders, NGO’s, Civil societies, churches to raise awareness on AMR Island leaders, NGO’s, Civil societies, churches > Engage island leaders, NGO’s, Civil societies, churches, raise awareness on AMR > Hold annual awareness campaign to celebrate World Antibiotic Awareness Week Page 19 of 38 > Hold annual awareness campaign to celebrate World Antibiotic Awareness Week 2.1.2 Improved knowledge, Attitude and Practice in public, health care workers and farmers on the use of Antimicrobials > Conduct AMR Knowledge Attitude and Practice survey for public, health-care workers and farmers (year 2) NDTC/AMR Sub committee > Conduct AMR Knowledge Attitude and Practice survey for public, health-care workers and farmers (year 5) NDTC/AMR Sub committee 2.2 Promote effective sanitation and hand hygiene in the community setting 2.2.1 Effective sanitation and hand hygiene in the community promoted > Participate in the world hand hygiene day Ministry of Health, health facilities > Participate in the world hand hygiene day Relevant ministries > Participate in the world hand hygiene day Relevant ministries > Develop promotional materials to raise awareness on hand hygiene and > Conduct regular hand washing campaigns using various means of communication > Conduct regular hand washing campaigns using various means of communication in particular radio or social media Page 20 of 38 effective sanitation in the community in particular radio or social media 2.2.2 Education curriculum of schools revised to capture AMR, basic sanitation and hand hygiene > Revise the Education curriculum to capture AMR, basic sanitation and hand hygiene awareness raising in primary schools Ministry of Education > Revise the Education curriculum to capture AMR, basic sanitation and hand hygiene awareness raising in high schools Ministry of Education 2.3 Raise awareness and educate health care professionals and livestock officers on AMR 2.3.1 AMR included as core component of professional education, training for health-care workers > Include AMR as a component of CPD for doctors Ministry of Health, PMH > Include AMR as a component of CPD for nurses Ministry of Health, PMH > Include AMR as a component of CPD for all health care workers Ministry of Health, PMH > Enrol health care workers in AMR course offered on POLHN or other institutions (FAO, OIE). > Enrol health-care workers in AMR course offered on POLHN or other institutions (FAO, OIE). Page 21 of 38 2.3.2 Livestock officers trained on AMR and good husbandry practices > Training module on AMR and good husbandry practices for farmers Department of Agriculture, FAO > Training module on AMR and good husbandry practices (part II) for farmers Department of Agriculture, FAO Page 22 of 38 3. Establish mechanisms for surveillance and research on AMR Goals Year 1 Year 2 - 3 Year 4 - 5 Activity Responsible Agency Activity Responsible Agency Activity Responsible Agency 3.1 Establish functioning microbiology laboratory capacity in human and animal health sector 3.1.1 Laboratory staff capacity on microbiology and quality antimicrobial susceptibility testing in human health strengthened > Build capacity of laboratory staff to conduct microbiology testing and analysis of antibiogram Ministry of Health, PMH, with support of WHO > Build capacity of laboratory staff to conduct microbiology testing and analysis of antibiogram (refresher) Ministry of Health, PMH, with support of WHO > Train laboratory staff in conducting external quality assessment on AMR Ministry of Health, PMH, with support of WHO, PPTC 3.1.2 The infrastructure of sole human health laboratory in the country upgraded to conduct AMR surveillance in human health > conduct needs assessment on the capacity of the laboratory PMH, Ministry of Health, AMR Committee > Procure and install new laboratory equipment + maintenance of existing equipment Ministry of Health, PMH, with support of WHO, > maintenance of equipment Ministry of Health, PMH, with support of WHO, 3.1.3 Laboratory > conduct feasibility on Department of Agriculture, > Conduct small study on AMR in animals Department of Page 23 of 38 testing capacity in animals established establishment of AMR surveillance in animals FAO OR Agriculture, FAO > Establishing animal health laboratory 3.2 Strengthen laboratory policy, standards and information system 3.2.1 Standard operating procedures for antibiotic testing developed and quality management system in the hospital laboratory introduced > Hire consultant to establish Standard Operating Procedures Ministry of Health, health facilities > Train designated personnel on Standard Operating Procedures (continued) PMH > Train laboratory staff in conducting external quality assessment on AMR PMH > enrol in an EQA system from Australia or New Zealand 3.2.2 Optimized supply chain of consumables of laboratory > Establish an inventory of consumables and reagents in laboratory PMH > Establish procurement routines / SOPs for supply chain of laboratory Ministry of Health, PMH > Procure lab consumables on a routine basis following SOPs Ministry of Health, PMH 3.2.3 Functional Laboratory Information System in use (egg WHONET) > Identify and hire consultant to install LIMS PMH > Build capacity of laboratory staff to use Laboratory Information management system Ministry of Health, PMH > Submit surveillance data to GLASS Page 24 of 38 3.3 Develop food testing capacity to combat AMR 3.3.1 Laboratory testing capacity for food residues and food imports established > Conduct feasibility of food testing for AMR priority pathogens Ministry of Health, Department of Agriculture. Ministry of Fisheries > Undertake random sample collection and testing for AMR and antibiotic residues. Ministry of Health, Department of Agriculture. Ministry of Fisheries > Identify and rent premises to build up food testing laboratory > Train food safety inspectors > Procure laboratory equipment and testing kits 3.4 Conduct research and strengthen information sharing on AMR 3.4.1 Strengthened knowledge and evidence based for AMR in Tuvalu Develop a standard template and mechanism for reporting AMR in Tuvalu Ministry of Health, PMH > Recruit an epidemiologist to analyse data and trends Ministry of Health, PMH > Develop a detail antibiogram for Tuvalu Ministry of Health, PMH > Build relationship with research institutions and WHO collaborating centre for AMR in Fiji, Australia or Page 25 of 38 New Zealand > Organize workshop to regularly share AMR surveillance data to key stakeholders, including regional and international > Organize workshop to regularly share AMR surveillance data to key stakeholders, including regional and international Page 26 of 38 4. Reducing incidence of AMR through effective infection prevention and control measures, food safety and hygiene Goals Year 1 Year 2 - 3 Year 4 - 5 Activity Responsible Agency Activity Responsible Agency Activity Responsible Agency 4.1 Strengthen national infection prevention and control activities 4.1.1 National Infection Prevention and Control guidelines implemented > Print and disseminate IPC guidelines in PMH and outer islands Ministry of Health, PMH, with support of WHO > Conduct training on infection prevention and control policy and guidelines targeting health care workers from outer islands and health administrators, livestock officers Ministry of Health, PMH, with support of WHO > Continue to implement National IPC guidelines at all facilities Ministry of Health, PMH, with support of WHO, PPTC > Conduct training on infection prevention and control policy and guidelines targeting health care workers from outer islands and health administrators, livestock officers > Continue to implement National IPC guidelines > revise/update IPC guidelines Page 27 of 38 4.2 Strengthen capacity of infection prevention and control staff and infrastructure (including waste management) 4.2.1 National Infection Prevention infrastructure and capacity strengthened > Appoint dedicated infection prevention and control officer in hospital Ministry of Health, PMH, with support of WHO > Ensure consistent availability of infection prevention and control supplies Ministry of Health, PMH, with support of WHO >Develop guideline on disposal of unused antibiotics (including veterinary medicines) Ministry of Health, PMH, Department of Agriculture > Allocate an office space for infection prevention and control officer > Enrolling health-care workers on infection and prevention control online course offered on POLHN or other institutions > Establish a safe space in the dump site for the disposal a) pharmaceuticals, b) medical waste and, c) veterinary waste > Ensure consistent availability of infection prevention and control supplies > Conduct infection prevention and control assessment of health facilities in 8 outer islands Page 28 of 38 4.3 Implement the Water, Sanitation and Hygiene (WASH) program to promote safe water and hygiene practices 4.3.1 WASH program in communities and schools strengthened > Implement WASH program in communities and schools National AMR committee Ministry of Health > Implement WASH program in communities and schools NDTC/AMR Sub committee Ministry of Health > Implement WASH program in communities and schools NDTC/AMR Sub committee Ministry of Health Ministry of Education Ministry of Education Ministry of Education > Conduct awareness training on WASH program in communities and schools > Conduct awareness training on WASH program in communities and schools (refresher) > Conduct awareness training on WASH program in communities and schools (refresher) 4.4 Promote good infection control and biosecurity practices in animal husbandry 4.4.1 Strengthen infection prevention and control in animal husbandry > Appoint part-time infection prevention and control officer for animal health sector National AMR committee Department of Agriculture > Develop infection prevention and control policy specific for animal farms NDTC/AMR Sub committee Department of Agriculture > Conduct training on infection prevention and control policy to farmers and livestock officers NDTC/AMR Sub committee Department of Agriculture > Print and distribute infection prevention and control Page 29 of 38 policy to all key stakeholders 4.5 Strengthen vaccination program in human and animal sectors 4.5.1 Tuvalu’s immunization programme strengthened and expanded > Continue to implement Tuvalu’s immunization programme (human health) Ministry of Health > Introduction of two new vaccines into EPI programme Ministry of Health, UNICEF, WHO > Establish vaccination programme in Agricultural sector NDTC/AMR Sub committee Department of Agriculture > Continue to implement Tuvalu’s immunization programme (human health) to reach set-out targets Page 30 of 38 5. Strengthen stewardship and monitoring on the use of antimicrobials in the human, and agriculture sectors 5.1 Strengthen regulations to promote responsible use of antimicrobials Goals Year 1 Year 2 - 3 Year 4 - 5 Activity Responsible Agency Activity Responsible Agency Activity Responsible Agency 5.1 Strengthen regulations to promote responsible use of antimicrobials, including EML and Aware and lists of antibiotics in animal sector 5.1.1 The use of prescription on antimicrobials in human and animal sector enforced > Review existing medicine legislation to cover the prescribing and use of antimicrobials in human health National AMR committee > Introduction of software to track prescription and dispensing NDTC/AMR Sub committee Chief Pharmacist > Review of treatment guidelines NDTC/AMR Sub committee > Conduct awareness on medicine legislation to medical doctors and other key health workers in Tuvalu > Updating of essential medicine list with introduction of AWARE categorization 5.2 Establish and develop national guidelines and programs to control the use of antimicrobials (including stewardship) 5.2.1 Antibiotic guidelines based on country antibiogram for human and animal use > Review and finalize the national antibiotic guidelines for human use National AMR committee > Develop and pilot antimicrobial stewardship (AMS) program in the main hospital NDTC/AMR Sub committee Ministry of Health, Department of Agriculture, PMH > Evaluate and revise pilot AMS programme NDTC/AMR Sub committee Ministry of Health, Department of Agriculture, PMH NDTC. Ministry of Health Page 31 of 38 developed and stewardship programme operational > Appoint coordinator for antimicrobial stewardship programme > Develop a national antibiotic guideline for animal use > Roll out national antibiotic guideline for animal use > Review the ToR of NDTC to ensure that it covers AMR-issues > Establish 3-5 years work plan for NDTC (including secure a budget) > Implement work plan for NDTC > Establish linkages between NDTC and AMR committee > Conduct training on antibiotic guideline and rational prescribing to livestock officers, medical doctors and other key health workers in Tuvalu 5.3 Establish antimicrobial consumption monitoring 5.3.1 Antibiotic consumption monitored > Hire consultant to conduct AMC study in Tuvalu in human health sector NDTC/AMR Sub committee PMH > Conduct Antibiotic consumption survey in PMH (if possible 1x every two years) NDTC/AMR Sub committee, PMH > Conduct Antibiotic consumption survey in PMH (if possible 1x every two years) > Regular sharing of AMR consumption data to key stakeholders, including Page 32 of 38 regional and international > Publish consumption survey data in annual health report 5.4 Strengthen procurement and supply of antimicrobials 5.4.1 Procurement and supply of antimicrobials strengthened (as part of improving access to medicines initiative in the country) > Participate in sub regional platforms to access information on quality of medicines/ antimicrobials Ministry of Health/Chief Pharmacist > Develop a strategy for sustainable procurement and supply of antimicrobials/essential medicines in human sector for Tuvalu NDTC/AMR Sub committee, PMH > Review policy on prequalification of antimicrobials that are imported to the country (in conjunction with consumption and surveillance data) NDTC/AMR Sub committee, PMH Page 33 of 38 > Optimize the use of Msupply™ in PMH > > Revise boarder control legislation to cover the declaration of all antimicrobials that enters the country >> Develop policy to control and guide the use of antibiotics on patients sent for overseas treatment including overseas doctors that will be visiting country for medical outreach > Train border quarantine officials to inspect and detect antimicrobials brought in from overseas 5.5 Strengthen understanding of pharmacovigilance in human health 5.5.1 Capacity to detect, assess, prevent adverse effects of antimicrobials established > Train the chief pharmacist on pharmacovigilance of antimicrobials NDTC/AMR Sub committee, PMH, Chief Pharmacist > Develop a report on adverse effect NDTC/AMR Sub committee, PMH, Chief Pharmacist > Establish a protocol to monitor and investigate suspected adverse effects Page 34 of 38 8.0 Implementation Framework 8.1 Strategic Operational Plan Upon the adoption of the endorsed Tuvalu National Action Plan on Antimicrobial Resistance, the NDTC/AMR Sub-committee will develop an annual Operational Plan for the five years. This will include detail activities linked to indicators and targets with responsibilities to help implement the National Action Plan on AMR. 8.2 Costing and M&E Framework The NDTC/AMR Sub-committee will develop a Costing and M&E Framework to assist in submitting for annual budgetary requirements linked to an aligned results-based M&E Framework. 8.3 Review and Evaluation The Tuvalu National Action Plan on Antimicrobial Resistance will be reviewed every three years, or more frequently if necessary. Page 35 of 38 Annex 1 Description of Governance Structure on AMR Cabinet: The cabinet is chaired by the Prime Minister and a direct line of reporting from the Government Advisory Committee highlights the political commitment to tackle AMR. The cabinet will provide high-level strategic and political support to the country’s response to AMR. The focal point in the Cabinet for AMR will be the Minister of Health and will act as the bridge between the Cabinet and the Government Advisory Committee (GAC). Government Advisory Committee (GAC): Terms of reference: • Coordinate and monitor country response to AMR and other emerging infectious disease across different ministries • Report to Cabinet within the prescribed timelines • Evaluate policies, regulations and guidelines related to AMR before passing for Cabinet endorsement • Assess and approve the National Drugs and Therapeutics Committee’s Policies, Proposals and Activities pertaining to the implementation of the National Action Plan on AMR before submission to Cabinet. National Drugs and Therapeutics Committee: Terms of reference: Pursuant to the Pharmacy and Products Act 2016, Part II, Sections 6 to 8. The NDTC shall be established and function under the purpose of the Act. In particular, for the purpose of integrating AMR as a priority health agenda, Section 7 (1) (n), “Undertake other functions that are specified in the National Medicines Policy.” • The Ministry of Health shall guide and direct the NDTC. • Support ministries, institutes, health facilities to implement the National AMR action plan • To coordinate and monitor activities related to AMR • Provide support to implementing line ministries, institutes, professional societies, partners as outlined in the National AMR plan • Mobilize both domestic and external resources and prioritize allocation of funds Page 36 of 38 • Review and update the national action plan and operational plan every yearly Membership: The Pharmacy & Therapeutics Act 2016 mandates the National Drugs and Therapeutics Committee to carry out its functions and will be chaired by the Director of Health and vice-chair is the Assistant Secretary of Health. The Committee shall consist of: the Chief Pharmacist; who shall be the Secretary; the Medical Superintendent; the Chief Dentist; the Chief Nurse/Matron; the Chief Public Health Officer. The Committee can include additional expertise that it may require from time to time in order to effectively carry out its functions. Chief and/or Director office holders from non-health Ministries and executive representatives from non-government entities will be appointed to the NDTC, to assist in the management of the National Action Plan on AMR 2021 – 2025 include: i. Ministry of Health • Support implementation of NAP in all matters pertaining to the human health sector ii. Ministry of Environment • Support implementation of NAP in the area of waste management, water & sanitation iii. Ministry of Education • Support implementation of NAP particularly for awareness/ educational activities in schools iv. Ministry of Transport and Customs (including telecommunications) • Support implementation of NAP particularly in area of import of antimicrobials • Support the implementation of NAP for awareness raising v. Ministry of Fisheries • Support implementation of NAP in rational use of antimicrobials in fisheries vi. Ministry of Home Affairs • Support the overall implementation of NAP vii. Ministry of Finance & Economic Development • Support implementation of NAP by providing necessary financial resources and budget space viii. Island/town councils Page 37 of 38 • Support implementation of NAP in the area of awareness raising, behavioural change on issues such as water and sanitation, immunization, promoting rational use of antibiotics ix. Council of Churches • Support implementation of NAP in the area of awareness raising, behavioural change on issues such as water and sanitation, immunization, promoting rational use of antibiotics x. Tuvalu Private Sector Organization (TNPSO) • Support implementation of NAP in the area of rational use of antibiotics xi. Non-governmental Organisations (NGOs) • Support implementation of NAP in the area of awareness raising, behavioural change on issues such as water and sanitation, immunization, promoting rational use of antibiotics Procedures of the Committee as stipulated in the Pharmacy and Therapeutics Act 2016, Section 8 (1) Subject to any requirements under this Act, or regulations, the Committee may regulate its own procedures, proceedings, and rules governing its meetings; (2) The Committee shall meet as often as is necessary for the efficient and effective conduct of its functions, and at such times and places as it determines; (3) The Committee can form sub-committees to enable it to efficiently and effectively undertake its functions; (4) The Committee shall prepare annually a report of its activities during the preceding 12 months and this report shall be made in writing to the Minister; (5) Any member of the Committee who has a material conflict of interest concerning a matter before the Committee must declare that conflict and take no part in the Committee’s deliberations on that matter. AMR Technical Working Group can be formed per strategic objectives of the AMR plan or technical program area as stipulated in the Act, Part II, Section (8) (3), “The Committee can form sub-committees to enable it to efficiently and effectively undertake its functions.” Page 38 of 38 Members (depending on activity and to be decided by the NDTC) • Team leader • 4-5 members Terms of reference: • To prioritize and support the implementation, monitoring of activities outlined in the National Action Plan on AMR 2021-2025. • Reporting to the National Drugs and Therapeutics Committee • Meeting & reporting time to be determined by the NDTC Advisors: In addition, the Government of Tuvalu has suggested attributing support roles to the National Drug Therapeutics committee as well as other relevant committees in various responsible line Ministries. WHO has been requested to provide technical support to the National Drugs and Therapeutics Committee to support the implementation of the National Action Plan. Other development partners such as DFAT, SPC, OIE, FAO, SPREP, UNEP will be requested to provide technical and financial support.