GAP-AMR, NAP-AMR, Strategic priorities. Containment of rise in use of antimicrobials in humans, animals as well as agriculture.

1. National Action Plan
on
Anti-Microbial Resistance
(NAP-AMR)

2. Background and Introduction
 World Health Assembly (WHA) and Regional Committee resolutions have
identified Antimicrobial resistance (AMR) as a universal threat to health, society
and economy.
 AMR is accelerated often due to misuse or inappropriate use of antibiotics in
humans and agriculture, insufficient hospital hygiene and improper disposal.
 India: Recognizes AMR as one of the top 10 priorities for the Ministry of Health
and Family Welfare and other related ministries of GOI, in collaboration with
WHO.

3. Contd …
 May 2015: The 68th World Health Assembly (WHA) endorsed the Global Action
Plan on Antimicrobial Resistance (GAP-AMR) – With antibiotic resistance as its
main focus.
 GAP-AMR provides a broad and basic framework for combating AMR.
 WHA resolution encourages the Member States to align their National Action Plan
(NAP) on AMR with GAP-AMR by May 2017.
The strategic objectives of the NAP-AMR are aligned to the GAP-AMR based on national needs and
priorities.

4. Goal of Global Action Plan (GAP) on AMR

5. India and AMR
India has high burden of bacterial infections and AMR is a major public health
concern with the old as well as new drugs making the circumstance far more
grave.
Staphylococcus
aureus
An increase from
29% to 47% of
Methicillin resistant
S.aureus (2008 -
2014)
Enterobacteriaceae
61% of E.coli were ESLP
producers , 51% Klebsiella were
resistant to Carbapenem; 61%:
Pseudomonas sp. to
ceftazidime and 42% to
imipenem.
S. typhi & V. cholerae
Resistant to Nalidixic acid,
ciprofloxacin, azithromycin;
And, ampicillin, furazolidone,
ciprofloxacin, azithromycin
respectively.

6. Contd …
 Major livestock industries contributing to AMR; Dairy (as early as 1970),
Poultry, Fishery sectors.
 Multi-country public awareness survey conducted by WHO in 2015, highlighted
important deficits in the understanding of antibiotics and their use.
 India: Higher use of antibiotics owing to financial incentives to prescribe
antibiotics and the role of the pharmaceutical industry. Hence, controlling AMR
is crucial for health and policy-making decisions.

7. Contd …
● National Health Policy 2017 highlights;
○ Calls for a rapid standardization of guidelines regarding antibiotic use.
○ Limiting the use of antibiotics as over-the-counter medications.
○ Banning or restricting the use of antibiotics as growth promoters in animal livestock.
○ Pharmacovigilance.
Prime Minister Shri Narendra Modi noted India's role on the Steering Group of Global Health
Security Agenda (GHSA), and its leadership in the area of antimicrobial resistance.

8. India: Use of antimicrobials and scope for future research
ANTIBIOTICS- HUMANS
India: Highest consumer.
March 2014: A separate Schedule H-1 incorporated into Drug and Cosmetic rules wherein
drugs under this category can be sold only with a proper prescription.
ANTIMICROBIALS IN FOOD ANIMALS
India: 4th highest in the world.
Expected to double by 2030
RESEARCH:
2004: Only 1.6% of the drugs produced were antibiotics and were not of novel class.
Innovation: Development of antibiotic resistance breakers (ARBs) to restore the
effectiveness of older classes of antibiotics.

9. NAP- AMR

10. Developing the NAP-AMR
● ICC - Oversee and coordinate policy decisions for
activities related to AMR.
● TAG - To review the approach and initiatives for
combating AMR in India and make
recommendations on technical issues.
● CWG - Provides technical and operational inputs
to the designated national coordinating centre for
AMR in India i.e. National Centre for Disease
Control (NCDC) to develop and implement NAP-
AMR.
INTERSECTORAL
COORDINATING
COMMITTEE (ICC)
TECHNICAL ADVISORY
GROUP (TAG)
CORE WORKING GROUP
(CWG)

11. Four pathogens of public health importance are being tracked:
Klebsiella spp, E. coli, Staphylococcus aureus, and Enterococcus spp
NCDC
12th Five-Year Plan
Objectives: Implementation and coordination of NAP for AMR.
Establish a laboratory-based AMR surveillance system of 30 network
laboratories, generating quality data on AMR for pathogens of public
health importance.
FUTURE PLANS
Extend testing of resistance to two more index bacteria:
Pseudomonas aeruginosa and Acinetobacter spp. Reporting from the
ten laboratories puts overall resistance rates to be very high, against
the commonly used fluoroquinolones, third-generation
cephalosporins and carbapenems.

12. GOALS of NAP- AMR
➢ Combat antimicrobial resistance in India
➢ Contribute towards the global efforts to tackle this
public health threat.
➢ Reduce the impact of AMR in India, it shall establish
and strengthen.
➢ Governance mechanisms.
➢ Capacity of all stakeholders.

13. of NAP-AMR
 Define the STRATEGIC PRIORITIES, key actions, outputs, responsibilities,
and indicative timeline and budget to slow the emergence of AMR in India.
 Strengthen organizational & management structures to ensure intra- & inter-
sectoral coordination with One Health approach.
 Combat AMR in India through better understanding and awareness,
strengthened surveillance, prevention of emergence and spread of resistant
bacteria through infection prevention and control, optimized use of antibiotics
in all sectors, and enhanced investments for AMR activities, research and
innovations.
 Enable monitoring and evaluation (M&E) of the NAP-AMR implementation
based on the M&E framework

14. Implementation of NAP-AMR
1. Strengthen Governance
2. Prioritize activities
3. Cost the operational plan
4. Mobilize resources
5. Implement prioritized activities
6. Monitor and evaluate

15. Strategic Priorities
Planned to be
implemented over 2017
– 2021 to tackle the
public health challenge
of AMR in India.
Ist Five strategic priorities
of NAP-AMR – Align with
Global Action Plan.
03
01 02 Sixth strategic priority -
India’s role in the
containment of AMR at
the international,
national and sub-
national/state level.

16. SIX
STRATEGIC
PRIORITIES
OF
NAP-AMR
1 - Improve awareness and understanding of AMR through
effective communication, education and training
2 - Strengthen knowledge and evidence through surveillance
3 - Reduce the incidence of infection through effective infection
prevention and control
4 - Optimize the use of antimicrobial agents in health, animals
and food
5 - Promote investments for AMR activities, research and
innovations
6 - Strengthen India’s leadership on AMR

17. STRATEGIC PRIORITY - 1
• Assess understanding, knowledge and awareness of antimicrobial
resistance (AMR) and antimicrobial use (AMU) amongst key
stakeholders/target groups.
• Document the existing communication and information resources and
products on AMR.
• Utilize communications to promote AMR awareness, targeting key
stakeholders.
Communication
and IEC
• Strengthen and consolidate AMR and related topics as core
components of professional education and training.
• Introduce concept of AMR and appropriate use of antimicrobials as
part of school curriculum.
• Strengthen capability and skills of key stakeholders.
• Improve inter-departmental as well as intersectoral
communication.
Education and
Training
AWARENESS AND
UNDERSTANDING

18. STRATEGIC PRIORITY - 2
• Strengthen capacity for laboratory-based surveillance of AMR in
humans, animals, food and environment.
• Designate national reference laboratories for AMR surveillance in
humans (also in animals, food and environment sectors) as a pre-
requisite for enrolment in GLASS.
LABORATORIES
• Strengthen surveillance for AMR in humans, animals, food and environment.
• Standardize data analysis and information management for AMR
surveillance.
• Strengthen AMR surveillance data/information management in human,
animals, food and environment.
• Establish surveillance of antimicrobial residues/contaminants in food and
environment.
SURVELLIANCE
OF AMR, HUMAN,
ANIMAL,
ENVIRONMENT
KNOWLEDGE AND
EVIDENCE

19. Need for improved surveillance system
● Absence of one health approach to surveillance
● Existing surveillance doesn’t account for Antimicrobial Resistance (AMR)
The existence of a surveillance system that can establish the relationship between
the antibiotic consumption patterns and emergence of AMR is vital to producing
evidence that may help in the designing and evaluation of effective interventions

20. STRATEGIC PRIORITY - 3
HEALTHCARE, HAI
ANIMAL HEALTH
COMMUNITY AND
ENVIRONMENT
INFECTION PREVENTION
AND CONTROL (IPC)
1. Develop and establish a stratified national plan for IPC in
health care.
2. Infection prevention in animal health.
3. Hygiene, sanitation and infection prevention in the
community.
a. Promote personal hygiene through behavioural change activities.
b. Strengthen infection prevention and hand hygiene compliance, in different
social groups
4. Align healthcare support industry with infection prevention
and control.
5. Reduce environmental spread of AMR.

21. STRATEGIC PRIORITY - 4
REGULATIONS,
ACCESS, AM USE
ANTIMICROBIAL
STEWARDSHIP IN
HUMAN HEALTH
AMS IN ANIMALS,
AGRICULTURE
OPTIMISE USE OF
ANTIMICROBIALS
1. Ensure uninterrupted access to high-quality antimicrobial medicines.
a. Strengthen national regulatory authorities for improved quality, safety and
efficacy of antimicrobials
b. Create/develop and enforce enabling regulatory framework and
intersectoral coordination for regulations on use of antimicrobials in
animals and food safety
2. Surveillance and monitoring the optimal use of antimicrobials in
humans, animals, agriculture and food sector.
3. Antimicrobial stewardship in human health
4. Strengthen the legislation regarding various facets of antimicrobials

22. STRATEGIC PRIORITY - 5
NEW MEDICINES,
DIAGNOSTICS
INNOVATIONS
FINANCING
INNOVATIONS, RESEARCH
AND DEVELOPMENT
1. Financing for AMR: sustainable funds for implementation of
the NAP-AMR.
2. Research and innovations:
a. Foster research and innovations to tackle AMR.
b. Prepare a national operational research agenda.
c. Encourage research for evidence-informed policy
making

23. STRATEGIC PRIORITY - 6
INTERNATIONAL
COLLABORATION
S
NATIONAL
COLLABORATION
S
SUB-NATIONAL
COLLABORATION
S
STRENGTHENING INDIA’s
LEADERSHIP
International:
1. Strengthen India’s commitment on AMR through collaborations
2. Strengthen international collaborations to promote India’s contribution towards
tackling AMR.
National:
1. Strengthen national collaborations to tackle AMR with disease control
programmes
Sub-national:
1. Strengthen sub-national collaborations to tackle AMR

24. Monitoring and Evaluation Plan (M&E):
• An integral part of the national action plan on AMR.
AIM: Ensure objective review and monitoring of the
implementation progress.
NAP-AMR: Interventions, Activities and Outputs:
1. Short term (S) with an expected achievement in one year.
2. Medium term (M), with an expected horizon of 1-3 years.
3. Long term (L) with a 3-5 years’ timeline.

25. THANK YOU