Regional Workshop on AMR in South East Asia Penang (Malaysia): 26-28 March 2018 Prof : Htay Htay Tin drhtayhtaytin@gmail.com DDG ( Laboratory) National Focal Point for AMR Ministry of Health and Sports Myanmar 1
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Myanmar National Action Plan on AMR (NAP-AMR) in Line with Global Action Plan on AMR ( GAP-AMR) as at 2018 January Presence of national AMR multi-sectoral committee and NAP-AMR in line with GAP-AMR - National AMR Multisectoral Committee (Established) 2018 January -NAP-AMR Launched..2017 July Awareness campaigns to the public -WAAW.. Held in 2017 November -Some government-led activities in parts of the country to raise awareness about AMR and actions to address it Education and training strategies for professionals -Relevant policies developed and ad-hoc training courses in some disciplines 4
National human AMR surveillance Laboratory capacity strengthening -Covering over 40 public hospitals -Guidelines developed but not fully implemented, limited quality data -N.H.L is recognised as National AMR lab of Myanmar at present -DDG (Lab) is National Focal point of Laboratory capacity strengthening Early warning systems No effective system in place 5
Rational use of antimicrobials and surveillance of Use & Sale National policy for control of human use of antimicrobials (AMR Stewardship Program, AMSP) National Drug Policy 2001 But weak to develop a plan to National AMSP NRA/DRA system set up for oversight but not fully functional National policy & plan on surveillance of use of antimicrobials under development or developed & approved but less implemented Rational use of antimicrobials and surveillance of Use & Sale Indicator 4.4 Regulation of finished antibiotic products and active pharmaceutical ingredients (APIs) Regulation with limited capacity but strategic planning in place for capacity building and appropriate budgeting - 6
Infection Prevention Control & AMR Stewardship program Indicator 5.1 AMR stewardship program in HCS -Awareness of Infection Prevention Control Committee and Team, SOPs, Guidelines, Job Description and Training to all level of health providers -Weekly supervision with checklist Infection Prevention Control & AMR Stewardship program Indicator 5.2 Surveillance of healthcare associated infections (HAI) - Weak surveillance of HAI 7
Infection Prevention Control & AMR Stewardship program Indicator 5.3 IPC program in HCS -Capacity building plans implemented in selected healthcare facilities _But cannot cover all levels of HCS Infection Prevention Control & AMR Stewardship program Indicator 5.4 Sanitation & hygiene and vaccination in the community Research & Development to Combat AMR Indicator 6.1 Research & development and innovation on AMR prevention and containment -Formal campaign to enhance sanitation & hygiene and vaccination is implemented -Hand hygiene campaign, Health Education, Symposium ) - Award to the best IPC of HCS Very few R&D -Existing structure has a plan to foster research and innovation on AMR 8
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20.1.2018 10
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2016, June 12
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NAP Governance Structure in Myanmar 15
National Multisectoral Steering Committee(NMSC) Combating AMR Myanmar Endorsed.. 2018 January Chairman.. Union Minister of Health and Sports 19 members from multisectoral in One-Health approach DDG ( Labs ).. Secretary 16
Common Bacteria associated with (HAI ) Hospital Acquired Infections : WHO High Priority Pathogens Staphylococcus aureus Pseudomonas aeruginosa Acinetobacter species Escherichia coli Klebsiella species 17
Percentage Antibiotic susceptibility patterns of Escherichia coli in Myanmar (2016) 100% 89% 88% 90% 80% 70% 83% 78% 66% 63% 56% 60% 50% 40% 52% 51% 44% 44% 40% 40% 40% 34% 32% 32% 31% 29% 29% 27% 30% 20% 10% 0% 17% 8% Antibiotics 18
Percentage Antibiotic susceptibility patterns of Klebsiella species in Myanmar (2016) 100% 90% 80% 86% 82% 74% 70% 68% 67% 64% 60% 60% 60% 53% 52% 52% 50% 48% 50% 40% 30% 20% 10% 0% 40% 39% 38% 36% 34% 28% Antibiotics 19
Percentage Antibiotic susceptibility patterns of Pseudomonas aeruginosa in Myanmar (2016) 100% 90% 80% 70% 60% 50% 81% 81% 75% 75% 65% 59% 57% 57% 53% 53% 52% 49% 40% 30% 20% 10% 0% Antibiotics 20
Percentage Antibiotic susceptibility patterns of Staphylococcus species in Myanmar (2016) 100% 91% 90% 80% 70% 79% 77% 74% 74% 74% 72% 71% 69% 67% *MRSA 61% 60% 56% 55% 54% 60% 50% 40% 30% 20% 10% 11% 0% Antibiotics 21
Percentage Antibiotic susceptibility patterns of Acinetobacter species in Myanmar (2016) 100% 90% 80% 70% 79% 78% 78% 68% 62% 60% 50% 40% 30% 45% 42% 41% 40% 35% 28% 25% 24% 20% 10% 5% 0% Antibiotics 22
Percentage WHO High Priority Pathogens in Myanmar (ESBL producing Enterobacteriaceae, VRE and MRSA)(2016) 50% ESBL producing Enterobacteriaceae, 47% Methicillin-resistant Staphylococcus aureus, 40% 40% Vancomycin-resistant Enterococcus species, 30% 30% 20% 10% 0% Pathogenic Bacteria 23
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Myanmar National Policy on Health Laboratories had been disseminated in September, 2016 Development of National Strategic plan for Health Laboratories : NSPHL (2017-2022) was adopted in line with National Policy on Health Laboratories National surveillance for AMR is highly listed in NSPHL National Action Plan : NAP for AMR was endorsed in endorsed in July. 2017 according to GLASS. NMSC is endorsed on 2018 January.. Union Minister of MoHS is Chairperson 26
Role of NHL for AMR NEQAS Identification and Antibiotic Sensitivity Testing of Bacteria, (40) Central, Teaching, States, Regional and some District Level Hospitals (2017) Participate in International EQAS, NIH, Thailand National Data collection from Hospitals and support to SOPs, Guidelines Workshops on AMR (WHO)- Standard Laboratory Method and Management of Data Entry (WHONET training) Standing as Reference Laboratory for AMR 27
Current activities on AMR 1.Collaboration with National Centre for Global Health and Medicine (NCGM), Japan on their Whole Genome Sequencing of Multi-drug resistant Gram Negative Bacteria 2.Technical Collaboration Agreement : Advancement in Clinical practice through Microbiology Education between Ministry of Health and Sports, Myanmar & biomérieux Pte.Ltd (Singapore) ( 2018-2020) 28
Activities of World Antibiotic Awareness Week Nay Pyi Taw 23.11.2017 29
Activities of World Antibiotic Awareness Week 23.11.2017 30
Activities of World Antibiotic Awareness Week 23.11.2017 31
Current activities ( Symposium on Antimicrobial Resistance awareness at 46 th Myanmar Research Congress) 32
Laboratory perspective of combating AMR (64 th Myanmar Medical Conference) (20.1.2018) 33
Challenges in NAPAMR Limited Laboratory Capacity for AMR Human resource Skill and training regarding clinical microbiology laboratory for Microbiologists and technicians, staff rotation Staff motivation Machines, Materials & Instruments for C&S Conventional C& S Automated Vitek2, Bact Alert (FOC?/Budget?) Limited number of Biosafety Safety Cabinet Budget for full laboratory capacity support?? 34
Challenges in NAPAMR Communication Communication between clinicians and the laboratory persons in consulting antibiotic resistance pattern of various samples Limited use of antibiogram result by clinician Clinical notes & diagnosis on request form.. Inadequate Unaffordable LIS Laboratory Information system effectively Data storage and Reporting- Limited IT facilities and internet access in some labs (WHONET data analysis) 35
Challenges in NAPAMR Sample Collection & Transportation.. Quality and timely transportation of sample are critical considerations to get qualified AMR results. Space- Not enough working space Storage- Not enough lab equipments like refrigerator, deep freezer etc in some labs for samples storage Less awareness about the laboratory / health care associated infection, partly effected by their heavy workload and duties Waste disposal -Difficult to get uniform colour coated plastic bag and waste container according to biosafety guideline / autoclavable bag 36
Challenges in NAPAMR Limited use of antibiotic guidelines and antibiotic policy in some hospitals ( AMU) Monthly CME and 3 monthly meeting in some hospitals but no regular meeting in some hospitals Less functional hospital Infection control committee meeting annually/twice per year/quarterly Unlimited access to laboratory working area Antibiotic Stewardship Program -not started yet in many hospitals Coordination between area of human and animal health based on one health approach 37
Health Care Associated Infection Prevention and Control 38
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HIC,Strengthening Symposium February 2018 40
HIC,Strengthening Symposium February 2018 41
Current activities of IPC (Analysis of hospitals data as at Feb 2018) Building the Infection Prevention Control Committee and team in hospitals Awareness of Infection Prevention Control Committee and Team, SOPs, Guidelines, Job Description and Training to all level of health providers Weekly supervision with checklist Review and Reward 42
Current activities of IPC (Analysis of hospitals data as at Feb 2018) Providing the requirements to maintain the infection prevention control function Fumigation of Operation theatre and labor room biannually Following the hospital management guideline according to level of hospital Health education about IPC to communities Environmental sanitation activities collaborated with local authorities 43
Ways Forward (Short term) Hospital antibiotic policy guideline Infection control meeting - 3 monthly Monitoring and evaluation 6 monthly Cooperation between patients wards and supportive department Training and health education Clinicians and Laboartory cooperation in monthly basis upon hospital antibiogram analysis Requisition of separate budget for IPC 44
Ways Forward ( Short term) Requisition of equipment and machines for IPC Providing of clothing of patients and health providers IPC checklist in every patients wards Immunization of all health care providers with hepatitis B vaccine Installation of exhausted fan at infectious patients room 45
Ways Forward (Medium & Long term) IPC documents (IPC policy, strategy, plan and guidelines) Need national level IPC committee at MoHS.. -Compliance with IPC measures -Routine surveillance of hospital acquired infection Work closely with other national structure / department/ committee ( Multilateral cooperation) 46
Myanmar NEQAS of AST Started.. Since 2005 is EQAS provider and analyzer Now.. around 40 teaching hospitals, specialist hospitals and State / Regional level public hospitals are participated Then provide the data to WHONET 47
Joint External Evaluation Process, GHSA 1 2 3 4 5 6 Stakeholders Meeting for JEE (6-2-2017) Training on Internal Assessment Teams (21-2-2017) to (22-2-2017) Internal Assessment Teams Visit (15-3-2017) to (22-3-201&) Internal Assessment Teams Debriefing (6-4-2017) Report to WHO (10-4-2017) External Team Visit (3-5-2017) to (9-5-2017) 7 5 years Strategic Plan for JEE (11-9-2017) to (15-9-2017) 48
DDG ( Laboratory) National Focal point of JEE / IHR in 3 areas 1.National Laboratory System strengthening 2. AMR 3. Biosafety 49
JEE Report on Antimicrobial Resistance, Myanmar 50
JEE Recommendations on AMR, Myanmar Launch and disseminate the National action plan for detection and reporting of priority AMR pathogen ( Done at 2017 July) Sustain the quality and services of laboratories that are able to detect and report priority AMR pathogen aligned with the GLASS ( NHL as National AMR lab and WHONET courses) 51
Establish an evidence-based public communications program targeting audiences in policy making, human and animal health practice, the general public and professional on prudent use of antimicrobials ( Underway) Sustain the surveillance capacity of existing 25 (human) and 3 (animal) laboratory ( Now more on Human Health surveillance laboratory to 40 numbers ) 52
JEE Recommendations on AMR, Myanmar Sustain the quality assessment scheme of NEQAS Develop surveillance system for usage of antimicrobial in human and animal sectors (OH approach) Disseminate the National action plan that includes Hospital infection prevention and control program ( Done ) Implement according to the Hospital infection prevention and control program in NAP ( Underway) Achieve a national steering committee for AMR and technical working groups to coordinate and implement each objectives ( Established NMSC 0n 2018 Jan.. TWGs are developed accordingly) 53
Future Works To Be Done National AMR Surveillance National Laboratory Network Strengthening Early Warning System for emerging drug resistance trends Strengthening of IPC and AMR Stewardship Programe in Healthcare Setting WHONET...continuously implemented for epidemiological and laboratory AMR surveillance data entry, storage and transmission in human and animal sector labs & GLASS IT platform.. Will start soonest 54
Future Work To Be Done Surveillance of rational antimicrobial use Establish a systematic, standardized process to collect, assess and share data, maps and trends on AMR hazards Promoting establishment of One health surveillance Cooperate AMR knowledge in undergraduate and post graduate medical, nursing and basic health teaching curriculum 55
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