Consultation on a draft Global action plan to address antimicrobial resistance

Consultation on a draft Global action plan to address antimicrobial resistance The questionnaire is divided into four sections. The questions are broadly framed and intended to give you the opportunity to enter into some depth and explain your organization's viewpoint. While only questions marked with * are mandatory, we would appreciate answers to as many as possible. Where a choice of answer needs to be selected please highlight your answer. Before answering the questions, please refer to our list of supporting documents. http://www.who.int/drugresistance/amr-consultation/en/index.html About you 1. Name of individual respondent* (deleted) 2. Email address* (preference for official email addresses) (deleted) 3. Are you authorised to represent your organization or interest group?* YES 4. Organization Name* Chennai declaration initiative 5. Address of the organization* APOLLO SPECIALITY HOSPITAL 320 ANNA SALAI, CHENNAI, INDIA 600035 6. Organization website (if available) www.chennaideclaration.org 7. Country* India 8. Type of Organization* Government department, ministry or agency

Development or aid agency, foundation, trust or other funding authority International developmental organization Academic institution Civil society Private sector Other non-governmental organization (NGO) Other (please specify) Position statement by representatives of various Medical societies in India 9. Main sector of interest Human health Animal health Finance/economics Agriculture or food Environment Communication, education and community Other (please specify) 10. Would you like to be added to our mailing list to receive updates on the development of the global action plan?* YES General questions 1. From the perspective of your organization, what are the most important areas of concern in AMR? Chennai declaration document is prepared by representatives of medical societies in India and various other stakeholders. This is an Indian initiative, primarily aimed at tackling antibiotic resistance in India and other developing countries. Important areas of our concern are 1.No functioning antibiotic policies in most South Asian countries including India. 2. Very high antimicrobial resistance in South Asian countries 3. Unregulated OTC sale of antibiotics

4. Sanitation issues in the community 5.Antibiotic use in veterinary practice not regulated. 6. Inadequate awareness on resistance issues among health care professionals and general public 7.Inadequate infection control standards in Indian and other south Asian hospitals. 8.Inadequate training on infection control and antibiotic stewardship in the medical curriculum of India and other South Asian countries. 2. Is your organization currently involved in work related to AMR? YES If Yes, How? Chennai declaration is the first ever joint recommendation by medical societies and other stakeholders in India, to tackle antibiotic resistance issue. Chennai declaration provided a practical and implementable solution to tackle antimicrobial resistance challenge; suitable to the background scenario of heterogeneity of health-care system in the country. Declaration recommendations are already studied in detail by Indian Ministry of Health. We are in constant touch with Ministry of Health officials on a daily basis. Ministry of Health has held multiple meetings to discuss Chennai declaration recommendations. Declaration recommendations have undoubtedly helped in speeding up the tackling resistance efforts by Indian Health ministry. Chennai declaration recommendations are discussed on a regular basis in meetings and conferences of most medical societies in India. The document and the initiative created a serious attitude change among Indian medical community. Medical societies became more open about the resistance issue. Chennai declaration document has helped to create awareness among Indian public, as the details and the progress of the recommendations are widely reported in Indian media. Chennai Declaration recommendations are discussed in almost a dozen international medical journals. Many reputed international medical conferences and policy meetings have discussed the recommendations. This has helped in generating international opinion on the importance of tackling resistance activities in developing countries. Questions about the draft global action plan outline document Before the WHA resolution was adopted, two WHO AMR Strategic Technical Advisory Group (STAG) meetings were held in anticipation, which included members plus a large number of representatives from other organizations. These meetings identified key issues, concerns and led to the development of a draft outline. As this consultation progresses and stakeholder meetings are held, the secretariat will harvest and incorporate the input into the draft global action plan.

1. How would you rate your understanding of WHO s intention in the development of a global action plan to address AMR? Very good Good Fair Poor Additional comments WHO must take active interest in tackling antibiotics resistance activities by moving beyond an advisory role, to the role of a real leader. 2. From the perspective of your organization, are the major issues relating to AMR outlined in the draft global action plan? Y If No, what additional issues need to be addressed? Most of the issue are mentioned. We must add the point that developed countries must help developing world in stepping up infection control and laboratory facilities in developing countries. Questions on the Building blocks described in the draft outline. You will notice, the global action plan has been constructed around building blocks in recognition that different countries will have different starting points. In this situation, countries can choose building blocks to concentrate upon. Each building block specified has been identified as a key area where specific attention, planning and work are needed to achieve progress in addressing AMR. Through questions in this section, we would like to hear your opinions on these building blocks in more detail. I. Building block-1: Increasing awareness and understanding about AMR and of the actions and changes needed a) What do you consider to be the main issues under this priority? In developing world: Health care professionals still lack understanding on the extent and the significance of antimicrobial resistance problem. Authorities in most developing countries not yet motivated to take initiatives to control resistance menace. Public not yet aware of the significance of the issue. Media participation inadequate in most part of the developing world b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo?

WHO to take initiative to coordinate actions to convince authorities in developing countries Chennai Declaration document and initiative in India made excellent progress in convincing medical societies and authorities on the importance of the resistance issue. Indian Ministry of Health studied the document in detail and the initiative played significant role in fast tracking the recent tackling resistance initiatives by Ministry of Health and medical societies. All countries in developing world should have similar initiatives. Chennai Declaration five- year plan is an ideal backbone for implementation and formulation of strategies. Authorities, medical societies, public, media and the health care industry are the main stakeholders. c) What steps have already been taken to address this priority? (Please provide references where possible) 1. In India representatives of medical societies, Health Ministry and other stakeholders organised a meeting A Road map to tackle the challenge of antimicrobial resistance, the first ever meeting of medical societies in India to discuss the resistance issue (August 2012) The Chennai declaration document and initiative is as a result of this meeting. Constant communication by Chennai declaration team with ministry of Health accelerated publication of the modified OTC rule, initiation of preparation of the National antibiotics guideline etc.. Chennai Declaration created a serious attitude change among Indian authorities, medical community to a significant extent. References Ghafur A, Mathai D, Muruganathan A, et al. The Chennai declaration: a roadmap to tackle the challenge of antimicrobial resistance. Indian J Cancer 2013; 50: 71 73. http://www.indianjcancer.com/preprintarticle.asp?id=104065 Team C. "Chennai Declaration": 5-year plan to tackle the challenge of anti-microbial resistance. Indian J Med Microbiol 2014;32:221-8. http://www.ijmm.org/temp/indianjmedmicrobiol323221-4847733_132757.pdf Kanungo R. Endorsing Chennai declaration and implementing the strategy. Indian J Med Microbiol 2014;32:109 http://www.ijmm.org/temp/indianjmedmicrobiol322109-4856297_132922.pdf Goossens H. The Chennai declaration on antimicrobial resistance in India.Lancet Infect Dis 2013; 13: 105 06.

d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) Chennai Declaration five year plan has explained these goals in detail. I have attached the document. Team C. "Chennai Declaration": 5-year plan to tackle the challenge of anti-microbial resistance. Indian J Med Microbiol 2014;32:221-8. http://www.ijmm.org/temp/indianjmedmicrobiol323221-4847733_132757.pdf II. Building block-2: Identifying the most important approaches for preventing development of infections and the steps needed to move beyond guidance to more effective implementation of such approaches a) What do you consider to be the main issues under this priority? In developing countries lack of infrastructure to follow infection control precautions and guidelines is the main impediment. Lack of awareness on the importance of the issue is also a major factor. Sanitation issues in the community setting is an important risk b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? Basic facilities in hospitals in developing countries should be improved. Governments in developing countries to devote more funds for this purpose Developed world to help developing countries financially and technically to improve infection control standards. c) What significant work has already been done to address this? (Please provide references where possible) An attitude change (to acceptance of the problem) is the most important first step in tackling any issue. In India Chennai Declaration initiative created this attitude change among Indian medical societies and the authorities. This attitude change has resulted in multiple meetings at highest levels in Indian Government to tackle the resistance issue. The results are already evident in the way Indian authorities acknowledge the resistance issue and participate and collaborate in the tackling resistance and infection control initiatives at national and international level. d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) Chennai Declaration five year plan has explained these goals in detail. I have attached the document.

Reference also provided. III. Building block-3: Optimizing the use of existing antimicrobials for human and animal health and in agriculture a) What do you consider to be the main issues under this priority? Lack of functioning antibiotics policies in most developing countries, to rationalise human and veterinary antibiotic use. Inadequate awareness on the importance of rational antibiotic use and resistance issue, in most developing countries. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? All developing countries must formulate an antibiotic policy and whole-heartedly take efforts to implement it to the best of their ability. A step by- step strategy will be ideal for developing countries, starting with a liberal policy and then made stricter once success of early stage is ensured. The new over the counter sale rule in India is based on this strategy. Chennai declaration document has explained the strategy in detail. c) What steps have already been taken to address this priority? (Please provide references where possible) India has already published a modified rule (H1 rule) to rationalise the OTC antibiotics sale. The implementation is in early stage. Once succeeded, will provide the best strategic example to be followed by all developing countries. d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) Chennai Declaration five year plan has explained this in detail. Document and reference attached. IV. Building block-4: Identifying and closing critical gaps in knowledge needed to address AMR a) What do you consider to be the main issues under this priority? Most developing countries do not have nationwide surveillance system and hence do not know the real extent of the problem. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo?

1. Health ministries of all developing countries must take initiatives to establish a national surveillance system 2. WHO should be the agency the coordinating various national networks, developing a global network. c) What steps have already been taken to address this priority? (Please provide references where possible) Some developing countries have networks but mostly inadequate. d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) Chennai declaration five year plan attached. V. Building block-5: Developing an innovative and sustainable approach to develop and distribute critical products and technologies needed to address AMR a) What do you consider to be the main issues under this priority? Lack of enough research to develop new antibiotics, especially ones against Gram negatives. The only immediate solution to the resistance problem is development of new antibiotics. b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? Enhancing research to develop new antibiotics. Pharmaceutical industry and Governments c) What steps have already been taken to address this priority? (please provide references where possible) There have been efforts to address the issue, but needs more momentum at international and regional level d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) Strategy for developing countries explained in Chennai declaration five year plan VI. Building block-6: Assessing the long term economic, developmental and social costs and implications of AMR as a basis for sustainable investment and action a) What do you consider to be the main issues under this priority?

Inadequate investment by Governments on tackling resistance issue b) What are the main actions that needs to be done -- and who are the main actors/stakeholders who need to take action -- to go beyond the status quo? 1. Investment to improve sanitation issues in developing countries. 2.Investment in improving infection control standards in hospitals 3. Investment to improve laboratory network in developing countries. c) What steps have already been taken to address this priority? (please provide references where possible) Indian Govt. has announced a master plan to improve sanitation in Indian cities. Indian health ministry has decided to expand vaccination coverage Indian Health Ministry has allotted funds to tackle antibiotics resistance. d) What are concrete and measurable indicators of progress for this priority? (Including, for example, global and national goals to be achieved within 2, 5 and 10 years) Explained in Chennai declaration five year plan-attached. Concluding questions 3. What contribution would your organization be able to make in implementing the global action plan? 1. Will communicate and motivate Indian Health Ministry to implement the recommendations 2. Will motivate all stakeholders to cooperate in implementing the recommendations. 4. Additional input that you feel would be facilitate development of the GAP. We already have plenty of well-intentioned documents to tackle the resistance, prepared by various organisations. What the world needs is real action. Reproduced with kind permission of Chennai Declaration five year plan team and Indian Journal of Medical Microbiology(IJMM) Team C. "Chennai Declaration": 5-year plan to tackle the challenge of anti-microbial resistance. Indian J Med Microbiol 2014;32:221-8.

Chennai Declaration Implementation-Five Year Plan The Chennai declaration-five year plan is designed as a companion document to the original Chennai declaration. 1 Details on various components of the five-year plan are already elucidated in the declaration document. The proposal provides a time bound action plan to various recommendations of the declaration. Readers are encouraged to refer to The Chennai declaration document for details. http://www.ijmm.org/temp/indianjmedmicrobiol323221-4847733_132757.pdf

STRATEGY ONE YEAR TWO YEAR FIVE YEAR OVER THE COUNTER SALE OF ANTIBIOTICS (SCHEDULEH1 ) 13 Coordinator: DCGI/State Drug Controller 24 antibiotics included in the Restricted list (as per the modified H1 list published by MOH) 60% of all antibiotics to be included in the restricted list 90% of all to be included antibiotics in the restricted list IN-HOSPITAL ANTIBIOTIC MONITORING (STRATEGY AS PER THE CHENNAI DECLARATION RECOMMENDATION 1 ) All tertiary care***hospitals to have an antibiotic policy. ANTIBIOTIC POLICY All secondary care** and primary care* facilities to have an antibiotic policy. Coordinator: Hospital infection control committee Collaborator: State ICC, National Task Force, Hospital accreditation agencies HIGH END ANTIBIOTIC MONITORING Initiatives to implement the strategy 1 in all tertiary carehospitals.(app endix 1&2) All tertiary care hospitals following the strategy. Initiatives to implement the strategy in all secondary care hospitals. All hospitals following the strategy. ANTIBIOTIC STEWARD 1

Second opinion on high end antibiotic usage by an antibiotic steward available in all tertiary care hospitals. Second opinion by an antibiotic steward available in secondary care hospitals. SURGICAL ANTIBIOTIC PROPHYLAXIS MONITORING SHEET(APPENDIX 3) Surgical antibiotic prophylaxis monitoring sheet to be used in all tertiary care hospitals Surgical antibiotic prophylaxis monitoring sheet to be used in all secondary care* hospitals Surgical antibiotic prophylaxis monitoring sheet to be used in all primary* hospitals AN AUTONOMOUS ANTIBIOTIC POLICY ACCREDITATION AGENCY (APAA) (May be within NABH or as an independent body) should be constituted by State/Centre and all hospitals mandated to apply for accreditation it at a nominal fees. Initiatives to set up APPA All major tertiary care hospitals APAA accredited. Initiatives to get secondary care hospitals APPA accredited. All primary and secondary care hospitals APAA accredited. Insurance/Corporate and third party payers encouraged to send their clients only to hospitals accredited with such a policy. STEPPING UP INFECTION CONTROL FACILITIES IN HOSPITALS National task force formed. State infection control committees and District task forcesset up Coordinator: Hospital Infection control committee Collaborator: State ICC, Central task force, Hospital accreditation All tertiary and secondary care hospitals to have infection control Primary care hospitals to have infection control teams.

agencies. teams. Use of alcohol hand rub in all tertiary care facilities Alcohol hand rubs to be used in all secondary and primary care facilities. Measures to increase compliance to hand hygiene techniques in all health care facilities Isolation precautions strictly followed, in practice, in all tertiary care facilities, to the best of their ability. Isolation precautions to be followed in practice, based on the available infrastructure, to the best of their ability, in all health care facilities. NATIONAL ADVISORY BOARD (DOH/NCDC) TO PREPARE GUIDELINES FOR INFECTION PREVENTIONAND ANTIMICROBIAL STEWARDSHIP IN INDIA Guideline committee to initiate formulation of national guidelines. Guideline committee to publish national guidelines. Guideline committee to modify recommendations basedon prevailing resistance scenario and the success of various tackling resistance efforts. Coordinator: Directorate General of Health Services/National Centre for Disease Control (DGHS/NCDC) Collaborator: Medical Societies RATIONALISING ANTIBIOTIC USAGE IN VETERINARY PRACTICE Coordinator: State Animal Husbandry Department and State Drug Controller REGULATION OF ANTIBIOTIC USAGE IN VETERINARY PRACTICES Antibiotics used in human treatment to be banned as growth promoters in food animals To regulate prophylactic and metaphylactic usage of antibiotics in veterinary practice. All veterinary antibiotics should need prescription. Coordinator: State Animal OVER THE COUNTER SALE OF ANTIBIOTICS FOR ANIMAL USE

Husbandry Department and State Drug Controller Efforts to formulate regulations to rationalize OTC sale of antibiotics for animal use Initiation of implementation of the rule.sale of antibiotics only on the prescription slips of the veterinarians under their registered license number. Efforts to increase compliance to the policy Coordinator: State Animal Husbandry Department Restriction on sale of antibiotics to dairy farmers and unauthorized veterinary workers NATIONAL ANTIBIOTIC RESISTANCE MONITORING NETWORK. Collaborator: State Agricultural/Veterinary Universities and ICAR(Indian Council of Agricultural Research) and ICMR(Indian Council of Medical research) At district level Veterinary Hospitals to participate in the network, prepare data base of antibiotic resistance About 5 Veterinary Hospitals in each district participating in the network About 10-15 Veterinary Hospitals in each district participating in the network SETTING UP OF FACILITIES FOR ANTIBIOTIC SENSITIVITY TESTING OF MASTITIS AND CLINICAL SAMPLES FROM ANIMALS District level Tehsil level Block level MONITORING OF ANTIBIOTIC RESIDUES IN FOOD OF ANIMAL ORIGIN. National task force formed State level task force formed District level task force Coordinator: State animal Husbandry Department Collaborator: ICAR and State Agricultural/veterinary Universities STRICT COMPLIANCE FOR OBSERVANCE OF THE ANTIBIOTIC WITHDRAWAL PERIOD FOR FOOD ANIMALS. State level monitoring system Divisional level monitoring system District level monitoring system

CLINICAL RESEARCH TO EXPLORE EXISTING OPTIONS TO TREAT INFECTIONS DUE TO MDR GRAM NEGATIVE BACTERIA Multicentre clinical studies on combination therapy against MDR Gram negative infections initiated. Results of the large multicenter trials published. Clinicians able to choose the best combination against these bacteria India to be making a significant contribution to academic world knowledge on treatment of MDR bacterial infections. Coordinator: ICMR MEDICAL COUNCIL OF INDIA AND CURRICULUM CHANGES Coordinator:MCI(Medical council of India) Collaborator:DME(Directorate of Medical Education) Preventive strategies, including decolonization trials Initiating discussions on necessary curriculum changes to encourage rational antibiotic usage and infection control (for doctors, nurses and pharmacists) Need community based studies on the prevalence of MDR bacteria New modules introduced into all medical schools. Discussions on extensive curriculum changes initiated. Implementation of protocol studies Modified curriculum introduced into all medical schools. MCI/National Board to take initiative towards DM/DNB training in ID Post-doctoral training in Infectious diseases (DM/DNB) started in at least 10 medical schools At least 50 medical schools starting infectious disease training

NATIONAL ANTIBIOTIC RESISTANCE MONITORING NETWORK 10-25 hospitals from each state participating in the network 50 hospitals from each state in the network 100 hospitals from each state in the network Coordinator: NCDC/ICMR Collaborator: NCDC/ICMR, state DOH NCDC /ICMR functioning as the national reference laboratory for antibiotic resistance studies Data available on molecular epidemiology of MDR bacteria especially Gram-negatives. Extensive nationwide data available on molecular epidemiology of MDR Gram-positive and -negative bacteria. ENCOURAGE RESEARCH TO DEVELOP NEW MOLECULES ANTIBIOTICS Coordinator: Council of Scientific and Industrial Research(CSIR) Collaborator:ICMR,Pharmaceutic al industry Discussion with pharma industry to identify molecules already in development and encourage the progression of promising leads Public private partnership to develop new molecules explored Fast tracking of promising antibiotics especially those active against MDR Gramnegative bacteria VACCINES Encourage research to develop new vaccines Promising vaccines identified and options to enhance

further research explored ACTIVE CONTRIBUTION OF MEDICAL SOCIETIES POSITION STATEMENT FROM ALL MAJOR SOCIETIES TOWARDS INFECTION CONTROL AND ANTIBIOTIC STEWARDSHIP All medical societies conducting CMEs on antibiotic stewardship and infection control (supervised by a neutral scientific committee) through their local branches-(25% of local branches coverage CONTINUING MEDICAL EDUCATION(CME) CME-50% coverage CME-100% coverage ACTIVE PARTICIPATION IN ANTIBIOTIC AWARENESS WEEK ACTIVITIES Active participation of half of all major societies Active participation of 2/3 rd of all major societies All major societies active and regular participation INTRODUCTION OF ONLINE MODULES ON ANTIBIOTIC USAGE. (Developed by National Antibiotic Guideline committee) 5000 doctors completing the module 50000 doctors completing the module. All registered medical practitioners completing the module. MEDICAL JOURNALS To publish editorials on tackling resistancein all major journals At least one article on the subject in every issue of the journal Indian journals to have a leading role in publishing papers on antibiotic resistance

ROLE OF MEDIA MOH to issue advertisements in visual and print media on rational antibiotic usage, directed at practitioners and public. Frequent articles and programmes on the subject in the media Active media participation in Antibiotic Awareness Week. NGO (NON -GOVERNMENTAL ORGANISATIONS) MOH and medical societies initiating discussion with NGOs seeking participation in tackling antibiotics resistance activities. Nationwide activities. Message reaching Indian villages Awareness activities in schools and colleges, clubs etc...in metros. Awareness activities in schools and colleges, clubs etc. in cities MEASURES TO IMPROVE Seek advice from experts in relevant Pilot schemes in Nationwide implementation of

SANITATION Coordinator: Ministry of Drinking Water and Sanitation(Ministry of Rural Development)/Ministry of Urban Development Collaborator: State Water Boards areas of public health, and various branches of science. Practical and implementable strategies identified. selected locations successful strategies. HOSPITAL ACCREDITATION AGENCIES (NABH, ISO ETC.) ROLE Strict monitoring on compliance to the infection control and antibiotic policy, during accreditation and reaccreditation process. NABH sending good practices advisory to all hospitals on antibiotic stewardship and infection control Conducting national antibiotic stewardship programmes for all doctors (nationwide) Capacity building for infection control nursing staff (nation wide) Sustaining standardized surveillance methods Establishing National, State Data collection and management and designing policies accordingly

STEPPING UP MICROBIOLOGY LAB FACILITIES ACROSS THE COUNTRY Tertiary care hospital labs should be able to perform culture from all kinds of samples. Secondary care hospitals should be able to perform culture of all kinds of samples. If unable to process, outsourcing of samples is an option All secondary care hospital labs able to perform culture and susceptibility testing of all samples using standardized methodology(as per ICMR surveillance network recommendation) Primary care facilities able to perform Gram stain and AFB stains. All tertiary acre and secondary care hospitals in the country following standardized methodology to perform cultures and susceptibility testing of all samples. COMPUTERISATION. SOFTWARE BASED PROGRAMME: Eg: WHONET All tertiary care hospitals using WHONET software All secondary care hospitals using the software Nationwide data available via online data entry in a designated website *Primary care centers: Hospitals with fewer than 100 beds and no NABL-accredited microbiology laboratory. ** Secondary care centers: Hospitals with fewer than 500 beds, not having an NABLaccredited laboratory ***Tertiary care centers: Hospitals with more than 500 beds or hospital of any bed strength with an NABL-accredited laboratory