Canada s Activities in Combatting Antimicrobial Resistance Presentation to the JPIAMR Management Board March 29, 2017
AMR in Canada Surveillance data indicates that rates of infection for some resistant pathogens have declined in recent years but remain above levels seen before 2007, indicating more work needs to be done: MRSA rates in hospitals have decreased by 25% since 2008 VRE incidence declined by 30% from 2012 to 2014 C. difficile infection rates have also dropped 35% in the 3-year period from 2011 to 2014 Neisseria gonorrhoeae is of particular concern: Canada has seen a 43.1% increase in the rates of reported cases between 2004 and 2013, and over 50% of isolates were shown to be resistant to at least one antibiotic, including higher azithromycin resistance levels than in the US and UK (3.3% in 2014, up from 0.35% in 2009) Medically important AMU in animals is significant: 73% of antimicrobials distributed to animals in Canada were of the same classes as those antimicrobials used in human medicine In 2014, approximately 82% of medically-important antimicrobials were distributed and/or sold for use in food-producing animals. 2
Federal Framework and Action Plan on AMR Launched in October 2014, the Antimicrobial Resistance and Use in Canada: A Federal Framework for Action mapped out a coordinated, collaborative federal approach for responding to AMR. In particular, it laid the foundation for action across multiple sectors, and outlined the key focus areas and plans for action of the Government of Canada. Subsequently, in March 2015 the Government of Canada followed up with the Federal Action Plan on Antimicrobial Resistance and Use in Canada: Building on the Federal Framework for Action. This document identifies concrete steps that key departments and agencies of the federal government will take to prevent, limit and control the emergence and spread of AMR. Actions were particularly focused in the areas of surveillance, stewardship and innovation. These documents set the stage for further action on AMR, and lay the foundation for Canada s national action plan, as committed to during the World Health Assembly in 2015. 3
Federal Response to AMR and AMU 4
Federal Framework (2014) and Action Plan (2015) on AMR Key results to date: Enhanced integrated surveillance activities (CARSS) Initiation of pilot projects addressing surveillance gaps (AMRNet; ESAG) Implementation of regulatory and policy changes for veterinary antimicrobials to enhance regulatory oversight Stewardship strengthened through engagement of practitioners via awareness campaigns and learning activities, and updated clinical guidelines on STBBIs Launch of research initiatives focused on AMR point-of-care diagnostics F/P/T multi-sectoral governance established to deliver pan-canadian Framework and Action Plan Stakeholders are undertaking complementary actions: HealthCareCAN: Stakeholder-led healthcare antimicrobial stewardship action plan (human) and network Canadian Veterinary Medical Association: Pan-Canadian framework on veterinary oversight National Farmed Animal Health and Welfare Council: National stewardship efforts in the agri-food sector 5
Towards a National Strategy: Pan-Canadian Framework on AMR The Pan-Canadian framework is a high level policy document outlining strategic objectives, outcomes and potential action areas under each of the components o Will guide and align collective actions within and across sectors with shared responsibility for AMR o Completion by May 2017 to meet Canada s commitment under the Global Action Plan on AMR With a Pan-Canadian framework we are trying to: o Coordinate and leverage actions being taken across sectors to eliminate siloes o Share information and best practices o Create opportunities for collaboration o Establish a coherent approach that will guide our collective efforts and ensure we are moving together in the same direction with clearly defined roles and responsibilities o Involve and engage all levels of government The Framework development is being facilitated through a dedicated governance structure that reflects a One Health approach with F/P/T government representation and human and animal health stakeholders. Key elements of the structure include: The AMR Steering Committee (senior F/P/T representatives) Task Groups (expert stakeholders from industry, academia, non-governmental organization and health and agricultural representatives from F/P/T governments) Deputy Minister Champions (human and animal health/agriculture from provincial and federal governments) 6
Foundation of pan-canadian Framework on AMR Surveillance Stewardship Infection Prevention & Research and Control Innovation Desired Outcomes Enhanced understanding of how AMR spreads in human and animal settings Comprehensive picture of AMR and AMU in Canada Effectiveness of current antimicrobial drugs of importance to humans maintained Health professionals and the public adopt appropriate antimicrobial use practices Reduced infections in health care and the community Better tools and approaches to detect and treat drug resistant infections in humans and animals Potential Actions Support the development of a centralized, harmonized database platform to integrate human and animal health data Identify priority organisms that contribute to AMR in animals and humans Enhance human AMR/AMU data collection in communitybased settings Strengthen the promotion of appropriate AMU in human and animal medicine Develop awareness, education and training to improve prescribing practices in human and veterinary settings Strengthen regulatory oversight and framework on veterinary medicines and medicated feeds Increase awareness and understanding of AMR, and the role that infection prevention and control play in limiting the spread of infectious agents Improve management practices to reduce the need for antimicrobials Increase awareness and understanding of the importance of biosecurity measures to limit the spread of infectious agents and the need for antimicrobial use Support the development of rapid diagnostics that guide the choice of treatment and therapeutic use Support clinical trials for drugs that are already on the market, and/or don t have other support Explore alternative and adjuvants to antibiotics as a made in Canada approach that addresses both veterinary and human medicine 7
Framework Components Surveillance Goal: Create strong, integrated surveillance systems to provide a comprehensive picture of AMR and AMU in Canada Areas of focus: development of clear objectives for AMR and AMU surveillance throughout the collection process; fostering of shared ownership of surveillance systems through active stakeholder engagement; promotion of centralized and standardized data sharing platform to integrate data across sectors; creation of clear technical guidance for all data-related activities, and standardized definitions for AMR Infection Prevention and Control Goal: Contain the spread of resistant organisms and reduce AMR and AMU, put in place standardized infection prevention and control approaches, programs and policies Areas of focus: development and delivery of effective communication, education, and training programs and tools to improve IPC; facilitation of the application and oversight of IPC best practices through regulations, guidelines, KT and education; collaboration with affected groups to address inequalities impacting the delivery of IPC programs; investments in IPC research to improve efficacy in both human and animal health 8
Framework Components Stewardship Goal: Creation of programs and policies that highlight education, awareness raising and increased regulatory oversight, to reduce inappropriate prescribing and use of antimicrobials in humans and animals to conserve the effectiveness of new and existing treatments Areas of focus: creation and funding of a pan-canadian Antimicrobial Stewardship Network; implementation of a robust AMU data collection system; implementation of regulatory and policy changes to enhance regulatory oversight; development of pan- Canadian harmonized governance tools; creation of enhanced educational curricula for prescribers and public awareness programs focused on AMR Research and Innovation Goal: enable evidence-based responses to AMR through increased knowledge, innovative tools and collaborative approaches to better understand resistance and develop new treatments and strategies. Areas of focus: support for a multi-sectoral network that will facilitate discovery, best practices and economic and production impact; investigation of alternatives and adjuvants to antimicrobials and development of R&I capacity; support for clinical and effectiveness trials of antimicrobials, alternatives and adjuvants; creation of a supportive environment for research and innovation; incentivize pharmaceutical investment in AMR by improving drug licencing processes 9
Pan-Canadian Framework: Lessons Learned Governance Model o Inclusion of federal, provincial and territorial governments, along with representatives from academia, industry, and NGOs in the governance structure fostered a shared sense of responsibility and ownership One Health Approach and cross-sectoral engagement o By including representatives from the human health, animal health, and agriculture in the development of the Framework, stakeholders have developed relationships that are extending beyond collaborations on AMR o Multi- and cross-sectoral engagement has also created interdisciplinary learning opportunities 10
Pan-Canadian Action Plan Once the Framework is complete the focus will turn to the development of an Action Plan to support implementation of the Framework objectives o o The Action Plan will lay out the details of concrete deliverables, measurable outcomes and timeframes On a longer track to provide opportunities for broad engagement and further discussion about what stakeholders can contribute, from ideas to implementation, within their sphere of influence Engagement may include events and activities such as stakeholder consultations through forums or conferences; a series of workshops; discussion guides for human and animal health stakeholders and/or government officials; etc. The ultimate goal of these activities is mobilizing commitment to framework implementation. In leading the development of the Action Plan, PHAC will continue to work with F/P/T partners and stakeholders across sectors. 11
Canadian Antimicrobial Resistance Surveillance System CARSS is the national coordinating program for PHAC s surveillance systems and programs that gather information about AMR and AMU in humans and animals CARSS uses data from PHAC s existing surveillance systems and national laboratory reference services to develop a national picture of AMR and AMU in humans and animals o This picture is intended to inform public health action (e.g., antimicrobial stewardship, infection prevention and control), research, and innovation CARSS: o provides integrated information on AMR/AMU surveillance; o informs the expansion of surveillance activities to areas of greatest need; o provides useful and relevant information to stakeholders and the public in support of antimicrobial stewardship interventions to further protect the health of Canadians Second CARSS Report released on September 12, 2016 (analysis of 2014 data) http://healthycanadians.gc.ca/publications/drugs-products-medicamentsproduits/antibiotic-resistance-antibiotique/antimicrobial-surveillanceantimicrobioresistance-eng.php 12
CARSS Contributors Canadian HIV Strain and Drug Resistance Surveillance Program Canadian Tuberculosis Laboratory Surveillance System (CTBLSS) Human antimicrobial use (AMU) surveillance National surveillance of antimicrobial susceptibilities of Neisseria gonorrhoae Canadian AMR/AMU surveillance information Canadian Nosocomial Infection Surveillance Program (CNISP) Laboratory reference services National surveillance of Invasive Streptococcal Disease Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) FluWatch 13
Prudent Use of Antimicrobials in Humans Putting the Pieces Together a Stakeholder-led Antimicrobial Stewardship Action Plan Antibiotic resistance information and awareness materials for Canadians and health care professionals through the Government of Canada website Pan-Canadian Public Health Network (PHN) Communicable and Infectious Disease Steering Committee Task Group Report on Antimicrobial Use Stewardship Do Bugs Need Drugs? - an education program for the community and healthcare professionals, providing resources for physicians, pharmacists, nurses, and the public Canadian Guidelines on Sexually Transmitted Infections (which include diagnosis and treatment of antimicrobial resistant gonococcal infections) AntibioticAwareness.ca which offers practical tools and information to practitioners and patients Choosing Wisely Canada, a campaign to help clinicians and patients Hospital-based stewardship programs 14
Prudent Use of Antimicrobials in Animals Canada is taking steps to strengthen veterinary oversight of antimicrobial use Veterinary Oversight of Antimicrobial Use A Pan-Canadian Framework for Professional Standards for Veterinarians was developed by the Canadian Veterinary Medical Association (CVMA) s Veterinary Pharmaceutical Stewardship Advisory Group and the Canadian Council of Veterinary Registrars Template of professional standards to be used by provincial and territorial veterinary regulatory (licensing) bodies when developing their own regulations, guidelines, or bylaws relating to veterinarians professional responsibilities in providing oversight of use of antimicrobials in all circumstances. The framework is intended to contribute to the development and implementation of uniform regulations across the country. Food animal producer associations are taking leadership in shaping their onfarm food safety programs Chicken Farmers of Canada Canadian Cattlemen s Association (CCA) Verified Beef Production Plus (VBP+) Canadian Pork Council (CPC) Canadian Quality Assurance Program (CQA) 15
International initiatives related to AMR Canada (PHAC, CIHR, CFIA) is one of the countries that co-leads the Global Health Security Agenda Action Package on AMR; will Chair starting in September 2017 Objective is to develop an integrated and global package of activities to combat antimicrobial resistance, spanning human, animal, agricultural, food and environmental aspects Canada collaborates with the US, EU, and Norway as part of the Trans-Atlantic Task Force on AMR (TATFAR) Current (3 rd ) phase involves a series of Action Items in 3 key areas: appropriate therapeutic use in human and veterinary medicine; prevention of drug resistant infections; and strategies for improving the pipeline of antimicrobial drugs In the fall of 2016, Canada joined the Global Antimicrobial Surveillance System (GLASS); established by the WHO to foster standardized AMR surveillance globally There are currently 31 fully registered countries, with 11 more expressing interest 16
Moving Forward In the coming months, the emphasis will be on several key activities Finalizing the pan-canadian Framework on AMR Launching the pan-canadian Action Plan process Strengthening AMR and AMU surveillance systems Continuing to collaborate with domestic and international partners on multi-sectoral initiatives to address the threat of AMR Ongoing exchanges of ideas with industry partners (how they could contribute to our initiatives and programs, how we could support their ideas) 17