South africas perspective on amr 17th icid reduced

South Africa’s Perspective on AMR Marc Mendelson @southafricanasp Division of Infectious Diseases and HIV Medicine Groote Schuur Hospital, University of Cape Town National Actions Contribute to a Global Solution • 3rd March 2016 • 17th ICID • Hyderabad

AMR in the [South] African context

Challenge 1 Health barriers (which may differ) in each country often need to be understood and addressed before the issue of antibiotic resistance ‘has room to breathe’

Situational Analysis, 2011

S Afr Med J 2011; 8

Outbreaks involving carbapenemase resistance genes in South Africa GES NDM VIM

KPC VIM

NDM Witbank

NDM KPC OXA-48-like VIM NDM GES

OXA-48-like GES NDM VIM SAMJ 2012; 102(7): 599-601

OXA-48-like GES J Clin Micro 2013; 51(1): 369-72

Slide courtesy of Adrian Brink

The scale of antibiotic abuse started to become evident 1 patient simultaneously received: Cloxacillin Teicoplanin Metronidazole Amikacin Ceftazadime Meropenem Levofloxacin Erythromycin Co-trimoxazole Fluconazole

Paruk et al. SAMJ 2012; 102(7): 613-6

Challenge 2 Maintaining impetus after the situational analysis.

Part of any intervention must be empowerment of the country to take responsibility and ownership of antibiotic resistance

Mendelson et al. S Afr Med J 2012;102(7):607-8

Adult Infectious Diseases Specialists

Paediatric Infectious Diseases Specialists

Infection Control Practitioners

Pharmacists

Surgeons & Intensivists

Microbiologists

Animal Health microbiologists & Veterinarians

Family Practitioners

Challenge 3 Need to decide where to start.

Few countries can focus on multiple areas in the beginning.

South Africa went for hospitals as the seat of most resistance

National AMR Working Group is formed under leadership of DG within Essential Drugs Programme

s r National AMR Summit, October 2014 e d l o h e k a t s l l a mit m o m r o f c n i o t y d u e B e : n 4 e ho g n w e l l a Ch

Antimicrobial Resistance National Strategy Framework Commitments The purpose of the Antimicrobial Resistance National Strategy framework is to provide a framework for managing Antimicrobial Resistance (AMR), to limit further increases in resistant microbial infections, and improve patient outcomes.

Governance Structures

Commitments

Strengthen, coordinate and institutionalise interdisciplinary efforts through national and health establishment level governance structures

Strategic objectives

Surveillance Optimise surveillance and early detection of antimicrobial resistances to enable reporting of local, regional, and national resistance patterns to optimise empiric and targeted antibiotic choice

Infection Prevention & Control

1.

Antimicrobial Stewardship

Promote appropriate use of antimicrobials Enhance infection prevention and in human and animal health through antimicrobial stewardship control of the spread of resistant microbes to patients in healthcare including: Effective policies and protocols settings, focusing Stewardship at point-of-care on improvement in hand National prescribing guidelines hygiene and the Appropriate antibiotic choice patients with resistant organisms.

Community measures include preventing infection through wide-reaching vaccination programmes and improvements in water and

2.

3.

4.

Strategic enablers

5.

Education of all levels of health providers in human health and agriculture in the critical concepts of antimicrobial stewardship, infection control, infectious diseases, microbiology and pharmacology.

Communication to educate the public, create awareness of the dangers of inappropriate antimicrobial use and enhance patient advocacy to combat antimicrobial resistance.

Research into novel diagnostics, such as point of care testing, new antimicrobials and implementation of treatment guidelines (treatment duration, antimicrobial consumption).

Short term – March 2015: Establishment and initial meeting of National Ministerial Advisory Committee

To establish a national surveillance system to track and report resistant organisms and Antimicrobial use in agriculture and human health To enhance the processes, structures, resources and supplies needed for effective Infection Prevention & Control

Short term 2015 - Develop an Antimicrobial Resistance map for South Africa through data sharing between the private and public sector laboratory services

Short to medium term 2015 - 2019: Strengthen governance at Health Establishment levels

Short term 2015 - Ensure the equipment and Infection Prevention & Control resources required to practice effective hand hygiene are available at all times in all Health Establishments Medium term 2016 – 2019 – All Health Establishments meeting compliance of the National Core Standards relating to Antimicrobial Stewardship and Infection Prevention & Control

sanitation.

Legislative and policy reform for health systems strengthening to support the quality of antimicrobials in the country and to enable control over prescribing of antimicrobials in the animal health sector.

Time Frames & Actions

To collaborate as intersectoral, interdisciplinary organisations and departments to strengthen, co-ordinate and institutionalise efforts to address Antimicrobial Resistance

6.

7.

To promote the appropriate use of Antimicrobials in human and animal health through antimicrobial stewardship in facilities and suitable enabling legislation and regulations

Short term 2015 – Ensure availability of Antimicrobials according to Essential Medicines List in all Health Establishments

To build the expertise and strengthen the competency of health and veterinary professionals workforce in Antimicrobial Resistance and Infection Prevention & Control To increase the community awareness of Antimicrobial Resistance

Medium term 2016 – 2019 - Development of strategy and operational plan for the integration and implementation of Antimicrobial Resistance and Infection Prevention & Control training into the undergraduate and post graduate medical curriculums of health care professionals in South Africa Short term 2014 – 2015 – Design of an awareness campaign relating to Antimicrobial Resistance based on past successful campaigns

Medium term 2016 – 2019 – Review of antimicrobials use in feed additives

To promote research into novel diagnostics and clinical trials in Infection Prevention & Control and Antimicrobial Resistance

National Departm ent of Health of the Republic of S outh Africa and P articipating S takeholders from Various S ectors, each Com pany represented herein as follow s: GOVER NMENT

LAB ORATORY S ERVI CES

National Health Laboratory S ervices

Department of Agriculture, Forestry and Fisheries

AMP ATH ( on behalf of P rivate Labs)

CLI NI CI AN S OCI ETI ES

S outh African Antimicrobial S tew ardship P rogramme

fede ration of infectious diseases societies of southern africa

CI VI L S OCI ETY

R EGULATORY S OCI ETI ES

Medicines Control Council

Treatm ent Action Campaign

S ection 27

S outh African P harmacy Council

S outh African Nursing Council

National Department of Health Médicins S ans Frontières

S outh African Veterinary Council

Department of S cience and Technology

S igned on this 16 th day of October 2014 in J ohannesburg as The Antimicrobial R esistance National S trategy Fram ew ork Commitments

Health P rofessionals Council of S outh Africa

Antimicrobial Resistance National Strategy Framework 2014-2024 Background

Framework

http://www.health.gov.za/index.php/component/phocadownload/category/199-antimicrobial-resistance

Impact: Rational Antimicrobial use and improved patient outcomes

Antimicrobial Resistance Governance

Enhance surveillance

Prevention Antimicrobial including IPC stewardship and vaccination

Health Systems Health SystemsStrengthening, Strengthening, Education and Communication/ Public awareness Research, Research,Education, Education,&&Communication Communication

Challenge 5 Development has clearly benefited from collaboration

South African Antibiotic Consumption 3 sources of data Animal use

Human use

Public use

Source

SARS import data 2010-2015

IMS data 2000-2010 Supplier order fulfillment data (CHAI)

Measurement

Tons

SU/1000 population

SU and DDDs

Increase

Pen/Strep 1 ton/y =141% increase

175% over 10y 58% if exclude trimethoprim

Analysis ongoing

Other 4.1 tons/y =11% increase

Public 360% Private 21%

Local produced Section 21

No split CA v HA Section 21

Excluded

No split CA v HA Section 21 Out of contract ABs

Staphylococcus aureus resistance to oxacillin (%MRSA)

Challenge 6 Creating national uniformity.

Towards equitable access to antibiotic stewardship expertise across the country

National Training Centres for Antibiotic Stewardship Groote Schuur Hospital

• One week courses – daily AS rounds and taught component • Teams of 3 – Prescriber + Pharmacist + Hospital Manager • Targeted at underserved provinces first

ANTIMICROBIAL PRESCRIBING LICENSE 1. BOYLES 2. Dr TOM 3. 20.09.1971 United Kingdom 4a. 16.10.2014 4b. National 5. Expires 15.10.2016 Web-based

6. Division of Infectious Diseases & HIV Medicine, Groote Schuur Hospital, Cape Town 7. Level 10 – full antimicrobial prescribing 22 podcasts with CPD accreditation forms the backbone of the training

https://www.openlearning.com/courses/clinical-antibiotic-stewarship-for-south-Africa

National AMR Issues in Animal Health

Antibiotics sold for animal health in South Africa, 2002 – 2004 Intramammaries (4%)

Other dosage forms (1.5%)

1. Penicillins (98%)

Water soluble (12%)

Parenterals (17.5%)

In-feeds (69%)

Eagar et al. J S Afr Vet Assoc. 2012;83(1)

5 Increasing colistin resistance in pathogenic 1 0 2 f o E. coli in South African Poultry operations er ce

t n r a a u sist q t re s la tin m lis o fr co l g m n / i l r r ¾ e 4 nf ≼ C co I e M n th ge i w -1 s R n i C a M r t s he i l o dt c . ine E 4 ta 2 / on 9 c 1

V-Tech, 11th an 2016

SA National Veterinary Surveillance and Monitoring Programme for Resistance to Antimicrobial Drugs

Governance issues

• NAPHISA will enhance health system effectiveness – Support, expertise and advice to government to achieve improvements in health of the population • Mandated to provide – Coordinated disease and injury surveillance – Research and training – Workforce development – Monitoring and evaluation of services and interventions directed towards major health problems affecting the population

http://www.nioh.ac.za/assets/files/NAPHISA_BILL_FOR_COMMENT_39392_gon1092.pdf

Antimicrobial Resistance National Strategy Framework Commitments The purpose of the Antimicrobial Resistance National Strategy framework is to provide a framework for managing Antimicrobial Resistance (AMR), to limit further increases in resistant microbial infections, and improve patient outcomes.

Governance Structures

Commitments

Strengthen, coordinate and institutionalise interdisciplinary efforts through national and health establishment level governance structures

Strategic objectives

Surveillance Optimise surveillance and early detection of antimicrobial resistances to enable reporting of local, regional, and national resistance patterns to optimise empiric and targeted antibiotic choice

Infection Prevention & Control

1.

Antimicrobial Stewardship

Promote appropriate use of antimicrobials Enhance infection prevention and in human and animal health through antimicrobial stewardship control of the spread of resistant microbes to patients in healthcare including: Effective policies and protocols settings, focusing Stewardship at point-of-care on improvement in hand National prescribing guidelines hygiene and the Appropriate antibiotic choice patients with resistant organisms.

Community measures include preventing infection through wide-reaching vaccination programmes and improvements in water and

2.

3.

4.

Strategic enablers

5.

Education of all levels of health providers in human health and agriculture in the critical concepts of antimicrobial stewardship, infection control, infectious diseases, microbiology and pharmacology.

Communication to educate the public, create awareness of the dangers of inappropriate antimicrobial use and enhance patient advocacy to combat antimicrobial resistance.

Research into novel diagnostics, such as point of care testing, new antimicrobials and implementation of treatment guidelines (treatment duration, antimicrobial consumption).

Short term – March 2015: Establishment and initial meeting of National Ministerial Advisory Committee

To establish a national surveillance system to track and report resistant organisms and Antimicrobial use in agriculture and human health To enhance the processes, structures, resources and supplies needed for effective Infection Prevention & Control

Short term 2015 - Develop an Antimicrobial Resistance map for South Africa through data sharing between the private and public sector laboratory services

Short to medium term 2015 - 2019: Strengthen governance at Health Establishment levels

Short term 2015 - Ensure the equipment and Infection Prevention & Control resources required to practice effective hand hygiene are available at all times in all Health Establishments Medium term 2016 – 2019 – All Health Establishments meeting compliance of the National Core Standards relating to Antimicrobial Stewardship and Infection Prevention & Control

sanitation.

Legislative and policy reform for health systems strengthening to support the quality of antimicrobials in the country and to enable control over prescribing of antimicrobials in the animal health sector.

Time Frames & Actions

To collaborate as intersectoral, interdisciplinary organisations and departments to strengthen, co-ordinate and institutionalise efforts to address Antimicrobial Resistance

6.

7.

To promote the appropriate use of Antimicrobials in human and animal health through antimicrobial stewardship in facilities and suitable enabling legislation and regulations

Short term 2015 – Ensure availability of Antimicrobials according to Essential Medicines List in all Health Establishments

To build the expertise and strengthen the competency of health and veterinary professionals workforce in Antimicrobial Resistance and Infection Prevention & Control To increase the community awareness of Antimicrobial Resistance

Medium term 2016 – 2019 - Development of strategy and operational plan for the integration and implementation of Antimicrobial Resistance and Infection Prevention & Control training into the undergraduate and post graduate medical curriculums of health care professionals in South Africa Short term 2014 – 2015 – Design of an awareness campaign relating to Antimicrobial Resistance based on past successful campaigns

Medium term 2016 – 2019 – Review of antimicrobials use in feed additives

To promote research into novel diagnostics and clinical trials in Infection Prevention & Control and Antimicrobial Resistance

National Departm ent of Health of the Republic of S outh Africa and P articipating S takeholders from Various S ectors, each Com pany represented herein as follow s: GOVERNMENT

LAB ORATORY S ERVI CES

National Health Laboratory S ervices

Department of Agriculture, Forestry and Fisheries

AMP ATH ( on behalf of P rivate Labs)

CLI NI CI AN S OCI ETI ES

S outh African Antimicrobial S tew ardship P rogramme

fede ration of infectious diseases societies of southern africa

CI VI L S OCI ETY

R EGULATORY S OCI ETI ES

Medicines Control Council

Treatment Action Campaign

S ection 27

S outh African P harmacy Council

S outh African Nursing Council

National Department of Health Médicins S ans Frontières

S outh African Veterinary Council

Health P rofessionals Council of S outh Africa

Department of S cience and Technology

S igned on this 16 th day of October 2014 in J ohannesburg as The Antimicrobial R esistance National S trategy Fram ew ork Commitments

http://www.health.gov.za/index.php/component/phocadownload/category/199-antimicrobial-resistance

Communication channels for MAC-AMR

http://www.health.gov.za/index.php/component/phocadownload/category/199

Raising Health Professional and Public Awareness of AMR and interventions

Incorporating AS and IPC into the South African Health Calendar World health day

World TB day Hand washing and cough etiquette 24th March

Flu day/we ek

Theme: Food safety 24 –30 April

World Immunisation Week

7 April

Infection Control Week (health care professionals and general public)

5th May

World Hand Hygiene day (health care Professionals) WHO SAVE LIVES: Clean your hands Campaign

June

15th Oct

Global Hand washing day (general public)

17-23 Oct

World Antibiotic Awareness Week 1-8 Sept

Pharmacy week

16-22 Nov

9th Dec

World Patient Safety Day

Involvement of (and with) international organisations • WHO Global Action Plan forms template for national plans • GHSA – 5 work packages including lead country for lab strengthening – One of lead countries R&D/Pipeline sub-working group • CDDEP – Technical advisor seconded to NDoH – Collaborative work on mapping and technical support • PHE/Commonwealth Twinning Program – SADC collaborative meeting planned to share experiences and resources towards aiding countries in developing national plans

South Africa as a Hub for AMR Support • Experience and strong leadership at NDoH (HIV, TB, Malaria), WHO (ABR - DG), GHSA (5 work packages) & Twinning Programs • National Public Health Institutes of South Africa (NAPHISA) – NHLS/NICD Surveillance • South African Antibiotic Stewardship Programme – one health, expertise, leadership & training • Clinical trials capability – basic science, therapeutics, diagnostics and vaccinology

Acknowledgements National Dept of Health

SAASP Co-chairs

•Ms Precious Matsoso (DG)

•Adrian Brink

•Dr Anban Pillay (DDG)

•Moritz van Vuuren

•Gavin Steel •Khadija Jamaloodien •Janine Munsamy •Kim Faure (CDDEP) •Stephanie Berrada (SIAPS)

All of our Partners

SAASP Working Group Leaders